Diagnosing and Treating Depression in Dubai

Introduction. Diagnosis and treatment for depression

depression diagnosis treatment Dubai. The picture shows a young woman with her right arm on the blue iron railing of a bridge. In the background we a river. The woman is wearing a light blue pullover. Her face expresses sadness and worries. The photograph captures the main signs of depression such as sadness, sorrow, low energy, resignation, and low self-esteem.

Depression is one of the most common and most underestimated illnesses with debilitating impact on people’s life. Therefore, we aim to shed light on various aspects of depression, its diagnosis, and treatment in Dubai.

Depression counts to psychiatric disorders characterized by a low mood, lack of interest or pleasure, and reduced energy level.

People with depression initially complain of general fatigue, loss of appetite, and sleep disturbances. These symptoms tend to increase over time leading to apathy, indecisiveness, social withdrawal, drop in professional performance and massive sleeplessness.

Depression is not just sadness, but a state with wide reduction of all emotions. Affected individuals describe this as a “feeling of emotional numbness”.

In some people the libido seems to implode. They get immobile, silent and can spend days in bet. Others, in opposite, feel restless and driven getting easy irritable.

Types of depression

The symptoms of depression vary. In the diagnostic procedure the psychiatrists use guidelines helping to identify a particular type of depression. The guidelines specify criteria such as anxious distress, mixed features, melancholic features, atypical features, psychotic features, catatonia, peripartum onset, and seasonal patterns.

The description “Clinical Depression” is not a proper psychiatric diagnosis. The term is used for depression with more severe symptoms which require treatment.

Major Depression

Condition matching the diagnostic criteria of ICD 10 or DSM 5 is called by psychiatrists Major Depressive Disorder (MDD). It’s categorized based on the symptom’s severity in mild, moderate, or severe episodes. The condition has episodic course and can continue for months, sometimes for years.

Depression with frequent episodes is called Recurrent Depressive Disorder.

In severe cases depression can create delusional thinking. Such depression is called Depression with Psychotic Features.

Dysthymia

Dysthymia is the old terms describing conditions with chronic depressive mood lasting for several years. The symptoms of dysthymia are not severe or persistent enough to meet the criteria for major, moderate, or mild recurrent depressive disorder. In DSM 5 the old diagnosis chronic depressive disorder and dysthymic disorder have ben unified under one diagnosis called “Persistent Depressive Disorder” (PDD).

Individuals with dysthymia feel low, lack motivation, and inadequate on most days. They tend to doubt themselves and feel inferior. They rarely experience joy experiencing non-specific physical symptoms such as fatigue, sleep disturbances, loss of appetite, or headaches. Even minor tasks are exhausting. Despite the difficulties, individuals with dysthymia can generally manage their daily lives.

In contrast, major depression is characterized by more severe symptoms and often occurs in phases (episodes). A depressive episode can be a one-time occurrence or recur at intervals. In dysthymia, the symptoms persist more or less constantly but with lower intensity.

However, dysthymia is associated with a high level of distress, primarily because the symptoms persist nearly continuously over an extended period with little variation in intensity. Women are diagnosed more often than men. The condition usually appears in adolescence or early adulthood, although people of all ages can be affected.

The causes are multifactorial such as genetic factors, dependence due to an overprotective upbringing and subsequent self-devaluation, and psychosocial influences such as social isolation.

Peripartum Depression formerly known as Postpartum Depression

The change from DSM-4 “postpartum depression” to DSM-5’s “peripartum depression” reflects evidence that around half of depressive episodes related to pregnancy actually occur prior to delivery.

The term “perinatal” refers to the period before and after the birth of a child. Perinatal depression includes depression that begins during pregnancy, called prenatal depression, and depression that begins after the delivery, called postpartum depression.

Pregnancy and the postpartum period expose women to significant biological, emotional, and social changes, making them vulnerable to depression and anxiety. Perinatal depression carries risks not only for the mothers but also for their children. Researchers found that the children of mothers who suffered of perinatal depression are at much higher risk to develop mental conditions mot only in the childhood. Also the mature individuals are at much higher risk to develop depression or anxiety in their later stages of life.

Pregnancy and the period after delivery is a particularly vulnerable time for women. During this time mothers are exposed to major biological, emotional, and social changes causing high risk for developing depression or anxiety.

“Baby blues”

Up to 2/3 of all new mothers experience the “baby blues,” a short-lasting and self-limiting condition which doesn’t impact severely mothers’ daily activities and does not require medical attention. Symptoms of “Baby blues” are emotional lability such as crying for no reason, irritability, and anxiety. These symptoms last for few days to maximum few weeks and disappear spontaneously without treatment.

Mothers affected with perinatal depression experience much more severe symptoms such as extreme sadness, emotional numbness and anxiety. Their sleep is disturbed, the energy level reduced limiting their abilities to carry for themselves and the child. Peripartum depression is a serious, but treatable medical condition. The treatment requires the use of medication or psychotherapy, or ideally the combination of both.

Perinatal depression does not have a single trigger. Similar to other psychiatric disorders perinatal depression might is caused by a combination of multiple factors such hormonal changes, genetic and environmental factors, the physical and emotional demands of childbearing and caring for a new baby.

Catatonic depression

Catatonic depression, is a combination of catatonia and depression. The condition is categorized under the DSM-5 as Major Depressive Disorder with Catatonic Features.

MDD

Major Depressive Disorder (MDD) has been described extensively in our other article. Major Depressive Disorder includes persistent low mood, decreased energy, and loss of interest. Additionally, feelings of sadness, hopelessness, difficulty concentrating, sleep and appetite disturbances are common indicators.

Catatonia

Catatonia is characterized by severe motor disturbances, such as rigidity and withdrawal. During catatonic episodes, individuals exhibit grimacing or refusal to eat. Immobility and mutism are the most prevalent symptoms, along with stupor, a state of dulled consciousness. Other characteristics of catatonia are:

Posturing and catalepsy, where someone maintains a position, are more severe manifestations of catatonia.
Stereotypies, repetitive and purposeless movements, are also observed, like rocking back and forth.

Echolalia involves repeating words spoken by others, while echopraxia mimics their movements.
Mannerism refers to performing exaggerated or odd actions instead of typical ones, such as hopping instead of walking.
Waxy flexibility, when resistance is followed by maintaining a manipulated body part’s position.

Catatonia is relatively common in psychiatric conditions, but its occurrence in major depressive disorder is rare. It is predominantly associated with bipolar depression. Bipolar disorder is the most frequently observed psychiatric condition associated with symptoms of catatonia, followed by schizophrenia.

Causes of catatonia

The causes of catatonia remain unclear, but several theories have been proposed. These include deficiencies in gamma-aminobutyric acid (GABA), dysregulation in glutamate and dopamine, as well as abnormalities in thalamic and frontal lobe metabolism.

The evolutionary theory suggests that catatonia may stem from an exaggerated primal fear response. Prehistoric ancestors, constantly facing predators, may have developed the ability to remain motionless for extended periods to avoid detection. Biologists observe catatonia by animals exposed to life threatening situations.

Treatment of Catatonic Depression

Catatonic depression requires a combination of treatments for both depression and catatonia. Given the potential life-threatening complications caused by catatonia, prompt intervention is crucial.

Benzodiazepines and electroconvulsive therapy (ECT) are the primary treatments for catatonia, with additional use of certain atypical antipsychotics to treat the depression in the later stage.

Benzodiazepines, particularly lorazepam, are the preferred choice, offering rapid relief from catatonic symptoms including associated anxiety and sleeplessness. They can be administered intravenously, through injections, or in tablet form.

Electroconvulsive therapy (ECT) is an effective treatment method, especially for malignant catatonia.

Once the most dangerous symptoms of catatonia are under control, the patient will be treated with a combination of antidepressants and psychotherapy.

Atypical depression

is a sub-type of Major Depressive Disorder with atypical features. The main characteristic is the mood reactivity with moods reacting strongly to environmental circumstances. The individuals suffering of atypical depression feel extremely sensitive. They experience profound fatigue, crave for food and face interpersonal difficulties. The patients feel leaden heaviness in arms or legs.

Unlike classic melancholic depression, atypical depression lacks features like insomnia, weight loss, and loss of reactivity of mood. The positive events don’t have any mood enhancing effect.

Increased appetite can be observed through a noticeable increase in food intake or weight gain. Hypersomnia may manifest as either an extended period of nighttime sleep or daytime napping.

Unlike other atypical features, pathological sensitivity to perceived interpersonal rejection is a trait that emerges early and persists throughout most of adult life. Rejection sensitivity occurs both during and outside of depressive periods, though it may worsen during depressive episodes.

Delusional or psychotic depression

Psychotic features include delusions or hallucinations. People who suffer from delusional depression may lose touch with reality and be misdiagnosed with schizophrenia. However, in contrast to schizophrenia, the delusional symptoms are related to personal inadequacy, his health condition, feelings of guilt, or financial security.

Agitated or anxious depression

Agitated or anxious depression involves worry and restlessness and anger and can be mistaken for anxiety disorder. People with this type usually do not feel depressed in the sense of feeling fatigued. They experience psychomotor restlessness. The person with agitated depression might move around, feel angry, and talk constantly, having shaky hands and racing thoughts. While being externally hyperactive on the inside, they feel confused and helpless.

Seasonal depression

The symptoms of seasonal depression are different from MDD that occurs year-round. They are less severe. This type is also called “winter depression” and occurs only in the dark part of the year, typically in winter. This form has similar diagnostic criteria to MDD, with two differences: In typical depression, there is a loss of appetite, and the sufferer loses weight. In winter depression, the opposite happens: there is increased appetite and weight gain. The other difference is in sleep: both forms can cause sleep disturbances, but in typical depression, the sleep is deprived (problems to fall and to maintain sleep), whereas in winter depression, people tend to sleep too much. Nonetheless, most depressions in winter are not winter depressions. The seasonal depression is very rare with prevalence in the general population of about one to two percent.

Masked depression

A Masked (hidden) depression isn’t used as a diagnosis anymore, but some psychiatrist still use the term to describe symptoms occurring with no obvious symptoms. The symptoms can only be identified on closer inspection. The focus is on physical symptoms of psychogenic (emotional) origin. Psychogenic pain appears real to those affected. Pain can occur in any part of the body. Patients may experience this as back pain, skin tingling, migraines, persistent headaches, chest pain, abdominal pain, etc.

Organic depression

This type of depression is the result of a physical illness. Some physical illnesses correlate with depressive symptoms. Evaluation by an experienced psychiatrist and thorough examination are critical for diagnostic differentiation and effective treatment.

How frequent is depression?

Depressive disorders are among the most common and most underestimated illnesses in terms of their severity. An estimated 16 to 20 out of 100 people will experience depression at least once in their lifetime. Results from a nationwide health survey show that at any given time, approximately five percent of adults between the ages of 18 and 65 suffer from depression.

The number of people with depression is rapidly increasing worldwide. According to a study by the World Health Organization (WHO), in 2015 depression affected approximately 322 million people, representing 4.4% of the world population. The WHO sees a particular need for action in young people, women before and after childbirth, and older people.

The causes of the rapid increase of the people affected are still unclear. The most plausible reason is the growing work pressure combined with social and financial instability. Currently depression became the leading cause of disability worldwide.

Treatment for depression

The treatment of depression needs time and requires a close cooperation with your psychiatrist and psychologist. The goal of the preliminary visit is to identify your problems and to decide which treatment method would be the most suitable. In case your symptoms are mild the treatment with psychotherapy would be the first choice. However, if your symptoms are more severe the combination of medication and psychotherapy will be necessary.

The prerequisite of a successful treatment is your compliance with your treatment plan. Don’t skip your regular visit by the psychiatrist and/or psychologist.

Relationship with the therapist

The warranty of a successful psychiatric treatment including the therapy for depression is a trustworthy relationship with your psychiatrist and/or psychologist.

You must be transparent with your psychiatrist reporting honestly about your worries, work, and private circumstances, as well as possible side effects of the medication. Based on your feedback the psychiatrist can adjust your medication. The psychotherapist may change the therapy goals or even refer you to other psychologist who’s training could be a better match for your particular problems.

Even if you’re feeling well, don’t discontinue or change the medication on your own. You should discuss any changes of the medication with your psychiatrist. Firstly, the risk of uncontrolled stopping the medication can be the reappearance of the depression. Secondly, by sudden discontinuation of the medication you will develop unpleasant symptoms such as mood swings, dizziness, or nausea. You can avoid such symptoms reducing or stopping the medication under the supervision of your psychiatrist.

The most effective treatment for depression is a combination of medication and psychotherapy. The medication can be prescribed by a psychiatrist, who is a medical doctor specialized in treatment of mental health disorders.

Treatment with antidepressants

Brain nerve cells use various neurotransmitters to transmit signals. While not all details are known, experts believe that in depression, the balance of certain neurotransmitters, such as serotonin, noradrenaline, dopamine or, glutamate are altered and some nerve connections are inhibited. Antidepressants aim to improve the availability of these neurotransmitters in the brain.

While there are many different antidepressant drugs, it is difficult to predict how well a specific medication will help an individual. Therefore, at the beginning of treatment, doctors often suggest a medication that they consider effective and relatively well-tolerated. If the medication does not work as expected, it is possible to switch to another one. Sometimes, various trials with medications are necessary to find the effective one.

Studies show that the benefit depends on the severity of depression: the more severe the depression, the more the benefits outweigh the drawbacks. This means that antidepressants are effective for chronic, moderate, and severe depression. They use is less successful for treatment of mild depression or dysthymia.

Course of treatment

Antidepressants are taken daily. In the first weeks and months, the goal is to alleviate symptoms and ideally make the depression disappear. Once this goal is achieved, the treatment is continued for at least 6 to 9 months. This so-called maintenance therapy is important to prevent relapses. Sometimes the medications are taken for even longer to avoid relapses (relapse prevention).

The duration of intake depends, among other things, on how the symptoms develop and whether there is an increased risk of relapse. Some people make need antidepressants for many years.

Monitoring of the pharmacotherapy

Regular doctor visits are important during the treatment. The doctor will discuss whether the symptoms have improved and if any side effects have occurred. If necessary, the medication dosage will be adjusted. Under no circumstances should you increase or decrease the dosage of the tablets independently, as this can result in insufficient effectiveness or more side effects.

Towards the end of the treatment, the dosage is gradually reduced over several weeks. Temporary sleep disturbances, nausea, or restlessness may occur when discontinuing the medication. Such symptoms mainly occur when antidepressants are abruptly discontinued. Discontinuing the medication on one’s own as soon as one feels better also increases the risk of the depression recurring. Unlike many sleep aids and tranquilizers, antidepressants do not cause physical dependence or addiction.

Treatment with psychotherapy

In patients treated only “biologically”, i.e. with medication, the symptoms can appear again despite of using the same dosage of an antidepressant. Consequently, adding the psychotherapy is a necessary part of an effective treatment improving by several times the chance for full recovery.

Clinical psychologists offer psychotherapy, or “talk therapy”, and have degrees in psychology and significant postgraduate training. Psychologists avail themselves of evidence based psychotherapeutic treatment methods, such as cognitive or psychodynamic therapies. At CHMC, the psychiatrist and psychologist work as a treatment team putting the patent’s needs first.

Behavioral Therapy

In depression, negative thought patterns such as self-doubt and guilt often reinforce feelings of sadness. In cognitive behavioral therapy, these patterns are gradually disrupted to cultivate a more positive self-image.

Cognitive behavioral therapy combines two therapeutic approaches:

Cognitive therapy: According to cognitive therapy, it is often not the things and situations themselves that cause problems, but rather the meaning we attach to them. Our personal perspective can be a crucial starting point for change.

Behavioral therapy: Behavioral therapy is based on the assumption that behaviours can be learned and unlearned. The therapeutic goal is to identify problematic behavioral patterns, work with them, and bring about change.

In cognitive behavioral therapy, the focus is on becoming aware of one’s thoughts, attitudes, and expectations. This enables the recognition and modification of inaccurate and distressing beliefs.

Psychoanalytic-based approaches

Analytical psychotherapy (known as psychoanalysis) and psychodynamic psychotherapy belong to the psychoanalytic-based approaches. They assume that unconscious, unresolved conflicts can cause depression. Through dialogue, previously unknown connections are sought and processed. A key requirement for psychoanalytic-based therapy is a willingness to engage deeply with past, potentially painful experiences. Psychoanalysis usually extends over a longer period than psychodynamic psychotherapy.

Systemic therapy

Systemic therapy places great importance on social relationships, such as those within the family, circle of friends, or workplace, as they can contribute to the development of depression. During therapy, efforts are made to improve communication within a family, for example. This is intended to help alleviate depressive symptoms.

How to avoid depressive relapse?

Depression is well treatable condition but requires professional help, that’s why you shouldn’t waste time and visit as soon as possible your psychiatrist or psychologist. An early therapeutic intervention shortens the treatment and improves its long-term outlook.

Be careful while judging your progress. Don’t overestimate a temporary improvement. It’s not uncommon to experience setbacks during the recovery process. Don’t expect a “quick fix” of the depressive symptoms. The process of healing takes time.

Pay attention to warning signs working with your psychiatrist and psychotherapist learning how to recognize the triggers.

Useful sources providing reliable information about depression

National Institute of Mental Health www.nimh.nih.gov

American Psychiatric Association www.psych.org

American Psychological Association www.apa.org

Depression and Bipolar Support Alliance (DBSA) www.DBSAlliance.org

National Alliance on Mental Illness www.nami.org

National Library of Medicine www.medlineplus.gov/healthtopics.html

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