19.6 Severe Depressive Disorder [Psychotic Depression; Manic Depressive Psychosis; Bipolar Affective Disorder]
(i) Depression is a word commonly used by people when describing feelings of unhappiness. However, depression becomes a recognisable illness when the degree of mood change is out of proportion to the circumstances and is unduly prolonged. It is also normal to feel elated at times of good fortune. Mania, however, is also a recognisable illness when the degree of elation (ie. elevated mood) is highly abnormal and frequently accompanied by overactivity and self important ideas.
(ii) "Affect" means the same thing as mood. In those conditions where the main feature is an abnormality of mood, the term affective disorders is sometimes used.
(iii) Severe depressive disorder is sometimes called psychotic depression because like other psychoses it is a severe mental illness in which there can be delusions and/or hallucinations. In this type of severe depression there is most commonly no apparent cause for the profound state of misery. Because of this it is sometimes referred to as endogenous depression. In other words, the symptoms are caused by factors within the individual person and are unrelated to external stressors such as unsatisfactory life situations. However there are people with endogenous depression who, though severely depressed, do not show psychotic features like hallucinations, etc.
(iv) When psychotic depression occurs in people who also have bouts of mania with intense feelings of well being and grossly overactive behaviour, the mental illness is called manic-depressive psychosis. Because of these swings in mood the illness may also be called bipolar affective disorder.
(v) Another form of depression is usually associated with an obvious cause (eg. bereavement, redundancy, failed marriage etc) and this form is usually a much milder illness. It is referred to as mild depressive disorder or reactive depression or neurotic depression Usually this is a mild depressive disorder but in some people with reactive depression individual responses to major adverse life events can precipitate more severe forms of depressive illness. [See paragraphs 19.7.7]. Physical symptoms (eg poor appetite, weight loss, constipation, loss of sex drive) occur to a varying extent in mild depressive disorder, but are commonly much less severe than in people with severe depressive disorder, and care and mobility needs are not usually present.
(vi) Post natal depression is a disorder which affects women shortly after childbirth. In the great majority of cases this is a mild condition (commonly called "the baby blues") which resolves spontaneously within a few days. A few women, however, develop a severe psychotic depression which may last several weeks and require hospital treatment.
(vii) This section is not concerned with feelings of sadness or elation as normal experiences but with those mental illnesses in which the single most important feature is disturbance of mood. Sometimes, even in medical reports from general practitioners the term "depression" is used rather loosely to describe states of unhappiness rather than the recognisable mental disorder.
19.6.2 Clinical Features: Severe Depressive Disorder:
(i) Each year around 100 per 100,000 men and at least three times as many women, develop severe depressive disorder. The mood is one of misery. It does not improve substantially in circumstances where ordinary feelings of sadness would be alleviated. However in some people with this illness the mood is usually worse in the morning and tends to improve somewhat later in the day. Pessimistic thoughts are also present. Feelings of hopelessness may occur with self-blame about minor matters. Slowness of thought may also be evident.
(ii) Lack of interest or enjoyment is common and leads to withdrawal from social activities. Reduced energy is characteristic with feelings of profound lethargy so that normal daily tasks are either not attempted or left unfinished.
(iii) Biological or physical symptoms are present. They include physical inertia, sleep disturbance, loss of appetite, loss of weight, constipation, and amenorrhoea in women of child-bearing age (absence of menstrual periods). Complaints about physical symptoms are common, sometimes with hypochondriasis (ie morbid anxiety about health). Suicidal thoughts may also occur.
(iv) In addition there may be delusions and hallucinations. These are usually centred around feelings of worthlessness
(v) Of all the severe mental illnesses, depression is the one most likely to respond to current medical treatment. The pattern of the depressive illness in the majority of cases is usually of recurrent episodes lasting several weeks or months interspersed with longer periods of normal mood. Some people experience only one episode and some are more or less continuously depressed for several years.
Mania
(vi) The central features are elation or irritability, increased activity and selfimportant ideas. The mood may be euphoric (intense feelings of well being) and may vary during the day. Overactivity is often persistent and can lead to physical exhaustion. The affected person is distractible starting many activities and leaving them unfinished. Sleep is often reduced; appetite is increased and in severe forms of the illness, sexual behaviour may be uninhibited. Women sometimes neglect precautions against pregnancy.
(vii) Expansive ideas of self-importance occur which at their extreme may be grandiose delusions. For example, the person may believe that he is a religious prophet or a world renowned expert on some matter. Persecution delusions may also be present. However the delusions are not long-lasting and usually disappear or change in content within days. Hallucinations also occur, usually taking the form of a voice telling the person that he has special powers, etc. Insight is impaired. The person seldom thinks he is in need of treatment.
(viii) In bipolar affective disorder or manic-depressive psychosis mania and depression may follow each other in a sequence of often rapid changes. Also included in this group are people with severe depressive disorder who may have had only one episode of mania. Moreover most people with mania eventually develop a depressive disorder. In any one year the incidence of bipolar affective disorders is 10-15 per 100,000 for men, and up to twice this rate for women.
(i) Suicide and attempted suicide are part of the pattern of some cases of severe depressive disorder. However fleeting thoughts of suicide are common in people with many mental health problems. In untreated severe depression, the only factor preventing suicide may be the associated apathy and physical inertia. The risk of suicide is therefore greatest in the early stages of treatment, when such symptoms begin to improve before there is any significant change in the overall mental state. Risk of self harm is also greater when moods swing from mania to depression or vice-versa. In these situations the person is likely to be hospitalised to guard against any risk. Only continuous supervision is likely to thwart serious suicide attempts in those at risk, and this is not practical in the home situation.
(ii) In those people with severe depressive disorder who show self-neglect there may be a need for care to maintain nutrition and cleanliness and to conduct essential business and communication. It must be remembered, however, that the majority of depressive episodes of this severity are of fairly short duration, counted in weeks rather than months. In very severe cases where the person remains motionless and mute hospitalisation is invariable.
(iii) In the great majority of people with severe depressive disorder the onset of the depressed mood is not so sudden that it demands continual supervision or watching-over at night. In people with mania who have grossly abnormal overactive and disturbed behaviour there may be a need for supervision and watching-over. Once recognised, however, treatment is instituted promptly, frequently in hospital, and in the very great majority within a few weeks there is a response to treatment.
(iv) When depression either accompanies or is a symptom of other co-existing disorders, such as alcoholism or substance abuse [See Chapter 22] or physical disability other care needs may be present.
19.6.4 Mobility Considerations
(i) Agoraphobia is a not uncommon feature of depression; it usually responds to antidepressant medication. Physical inertia and apathy may result in the carer needing to encourage the severely depressed person to get out and about. This, in itself, constitutes neither guidance nor supervision. The evidence will have to be scrutinized in the individual case to determine whether there is a need for guidance or supervision outdoors. It is unlikely however that features of this severity will last for more than a few weeks at any one time
. (ii) Apart from the rare occurrence of depressive stupor (motionless and mute) in very severely depressed people, neither the depressive disorder nor mania affects the ability to walk. Persons with depressive stupor will be hospitalised and respond to treatment within a period of weeks.
In the great majority of cases any evident care needs will only be for a limited period which is unlikely to exceed several months during any one episode.
(i) In all cases of severe depressive illness or bipolar affective disorders it is highly probable that a consultant psychiatrist will have been involved in the management and treatment of the individual. Indeed the absence of any documented history of a psychiatric consultation should raise doubts about the nature and/or severity of the given diagnosis.
(ii) Hospital factual reports should be obtained. Other sources of information will be community psychiatric nurses, general practitioners and mental health social workers.
(iii) In those instances where it appears that the claim pack has been inadequately or inappropriately completed by someone described as having a mental illness of the types described here, it would be helpful if a report were obtained from an examining medical practitioner.
