THYMIE:
Defined by Jean Delay, the thymie appears as a “variable” participating in psychic functioning of any individual, regardless of his personality, even if it influences changes in his mood. The existence of the “independent” variable is supported by our ability to evaluate it. The simple test is to rate our mood, for example in the morning, between 0 and 10. We easily manage, proof of our intuitive knowledge of this provision and its variations. Another argument, it is possible to raise the thymie of any person by a euphoric (amphetamines, cocaine, etc.). But natural mood swings, sadness to euphoria, which primarily relate to events that affect us. It is also possible to evoke the notion of “Reaching Out”, which we would have at birth. This momentum normally resistant to ‘accidents of life’ but its strength depends on many factors, innate and acquired: genetic background, educational climate, personal fulfillment, etc. Its strength also depends on the intensity and especially the frequency of tests encountered in existence.
CONDITIONS CRITERIA:
The criteria provided by the two references that are currently in psychiatry, ICD-10 and DSM-IV TR, are consensual but do not respond adequately to the essential question from how hard or how long the sadness makes a depressive syndrome. Although they offer statistical criteria but difficult to find during a physical examination, which in psychiatry, can not be an interrogation guided by a standardized questionnaire. We use scales (BPRS type) but only as part of research protocols. In our specialty as elsewhere, we must establish a connection, a relationship with the patient, so that it manages to express his resentment.
The reliability of our diagnosis is based on the externalization of his inner world, no diagnostic testing can not replace nor confirm.
Depressive episode according to ICD 10:
It mainly includes:
– Lowering of mood;
– Loss of interest and pleasure, decreased energy;
– Decreased concentration and attention;
– Decreased self-esteem and self-confidence;
– Ideas of guilt or worthlessness (even in mild forms);
– Morose and pessimistic attitude about the future;
– Self-injurious or suicidal thoughts or actions;
– Sleep disturbance;
– Decreased appetite.
It is also mentioned that the depressive episode should last for at least 2 weeks and can be mild, moderate, severe with presence or absence of psychotic symptoms.
When symptoms are unusually severe and quick setup, the diagnosis can be made before the period of two weeks. It is the same when there are authenticated history of depression.
Examination method:
To achieve genuine recognize depressive symptoms and gather in syndrome, it is proposed here a more meaningful review plan than a simple enumeration of disorders.
Presentation:
Careful observation of the patient, his facial expression, his look, his general presentation, attitude, allows a first-degree assessment of his thymie. The mere fleeting sadness may be the cause of mental distress and psychomotor slowdown emanating from the depressed. The care given to the dress and the hair, makeup, are clues for a non-pathological sadness, as well as the quality of contact, alertness and mobility actions.
Change Assessment:
This is whether the patient has recently changed, if not the same person, if there was a break with its usual operating mode. In this case, it must be within the time this “depression” in the sense of reduced mental pressure. This change must have manifested since at least 15 days so that we can talk about depression. It must be great enough so that the patient has the feeling, is in is worried, as his entourage who does not recognize it. It is not 2 or 3 days of spleen or gloom. It is not, conversely, chronic existential malaise. Indeed, there are people sad, pessimistic, humorless, dissatisfied with nature that the problem is rather neurotic or dysthymic register. In other words, depression, even if it persists or resists, must have an identifiable beginning and a sufficient duration.
Past, present, and future in the depressed:
This part of the review is to evaluate three essential components of the depressive core: the vision of his past by the depressed, the apprehension of her present and her future.
Vision of its past:
The depressed speaks only of failures. Sometimes we, on bad days, we set out some memories of failures but we manage to qualify them or compensate them with those of success. The depressed memory is cruelly selective. When asked about his past, this is an indictment: he disappointed his parents, he failed in his mission, he was incompetent to hear, he only mistakes in working life as in private life. It may even be more severe and acknowledge mistakes or offenses, self-accusations that feed the guilt of ideas.
Apprehension of this and himself:
It is painfully marked by anxiety worthlessness, anhedonia and emotional anesthesia. It is well beyond the simple sadness. Jean Delay, “the pain is depressed as basic and as instinctive as physical pain (…) it has nothing to do with boredom, melancholy or sadness that does not exclude the morose delectation. “.
The depressed believes a decline in efficiency, has slowed his thought, fueling his self-criticism and concern because this devaluation is anxiety.
He thinks also be a burden to those around him and society.
To highlight anhedonia, it may be useful to ask the patient about the circumstances or activities that usually make it fun.
In its current state, he has no taste for these things. More agonizing for him is the awareness not to experience the same emotional boost to his relatives. This move towards an emotional anesthesia is very feel guilty, as if it were desired.
Anticipation of the future:
Human beings need to anticipate. Most of the time, we know what we will do in the coming days and we spend a lot of energy trying to guess the future. Sometimes we are pessimistic, but with lucidity.
The depression, loss of vital energy, prevents to project into the future or only preserves a pejorative anticipation. The future can not be that the penalty of past mistakes, hence the ideas of ruin and incurability.
Possibility of suicide:
When the past is that failure, that this is crushed under a “wall of silence” and that there is no future, why go on living?
As soon as the depressed asks this question, it necessarily the pose, he comes to desire the end. The question on this point is not likely to suggest this idea because there is already thought. It usually starts like a disease or a fatal accident, and wondered about the best way to rush things. Suicidal logic is running. For the physician, to know is to contribute to the prevention of acting out.
Physical symptoms:
They are well known and highlighting is easier: sleep disturbance and appetite, weight loss, asthenia, fatigue and painful hyperesthesia. This last symptom is less classic, but savvy clinicians have noted and its correlation with depressive syndrome is demonstrated.
SOME CLINICAL FORMS:
Reactive depression or depressive reactions:
ICD 10, the depressive reactions are mild depression (short for <1 month, extended if> 1 month <2 years) in relation to a traumatic situation, a stressful event or an existential crisis. They are classified as adjustment disorders. The stress must be high and the temporal relationship therewith less than 3 months.
Sadness is normal after a loss, real or symbolic, after a break or failure, after a series of “mini-psycho-trauma.” The grief reactions are regarded as pathological because of their expression or their content and duration beyond 6 months.
In the area of reaction or depression depressive reactions, the boundary between normal and pathological field is difficult to trace.
Be sad after an unfortunate event is an expected, yet less and less accepted by society reaction.
What would really pathological in these circumstances would be a denial of paradoxical reaction or euphoria (manic mourning).
Recurrent depressive disorders:
They are characterized by repeated episodes.
Each episode (at least 3) persists for 3 to 12 months and the patient has no depressive symptoms between these episodes. These disorders are twice as common in women than in men, regardless of cultural background.
Persistent mood disorders:
Whether cyclothymia (bipolar mood fluctuation) or dysthymia (chronic depressive tendencies), it is the persistence for years (at least two) and not the severity which is the main feature of this clinical form.
Manic or bipolar illness:
Is referred to one of these two names the old manic psychosis (PMD) which fortunately lost his membership in psychotic register. The disorder is characterized by the occurrence of several episodes (at least two) in which the mood is disturbed, sometimes in the sense of an elevated mood (mania or hypomania), sometimes in the direction of its lowering (depression ), usually with complete recovery between episodes.
Bipolar disorder is equally common in men than in women.
TO BEHAVE:
Conventionally, to behave begs the following questions.
The sadness she relates to medicine?
Not because it is not a medical condition, but any doctor knows to be compassionate in these circumstances. The answer is not as simple when it comes to chronic sadness.
One of the problems of our society, lack of benchmarks is to be individualistic then being weakened should foster community support: family, group, neighborhood, town, parish, etc. The sad citizen often returns to the doctor and, since that antidepressants do not have the side effects of tricyclic, one is tempted to use it.
Should guide “chronically sad” to the shrinks?
Before responding, it may be useful to know the state of play. It is common to hear that there is not enough psychiatrists in France, whereas in the public sector, they are three times as many as in England for a population equivalent. Knowing that the incidence of mental illness is the same in both countries, it is conceivable that the French “consume” more easily psychiatrists across the Channel. In fact, the problem probably lies in access to psychotherapists psychologists who remains entirely patient management in our country. Thus, psychotherapy psychiatrists being preferred, liberal psychiatrists are saturated, even in sector 2, and medico-psychological centers (CMP) dedicated to the most seriously ill patients.
As highlighted in a recent report on psychiatry and mental health (Clery-Melin, Pascal, Kovess, 2003), there is confusion between psychiatric problems and mental suffering “even more common as the public evil distinguishes different problems severity levels … “and confusion” between care demand and need care. “ Ultimately, it should better distinguish between mental health issues and prevention, which are everyone’s business, and the problems of mental pathology, which are of psychiatry and medicine (a third of people who consults in general practice has a psychiatric disorder. anxiety, depression, addictions)
Should we prescribe antidepressants and which prescribe?
According to epidemiological studies, depression is undertreated by ignorance of diagnosis, usually because of the reluctance of the patient to admit and consult. And yet we are the largest prescribers of antidepressants. This disease is not particularly widespread in France, there is probably a problem of indication, both by excess and deficiency. This problem is related
the reliability of diagnosis, particularly during a self-diagnosis. This is to emphasize the importance of the method of examination in this area. When the diagnosis of depressive access is increased, supported over time, change, moral suffering and loss of life force recognized, an antidepressant should be prescribed. These drugs are not euphoric and do not cause addiction in the sense of addiction.
They do not create a biological disorder, but correct abnormalities in neurotransmission authenticated during depressive episodes.
The choice of product can be guided by the search for a stimulating effect in the great slow and rather sedative for great anxiety. Monotherapy is suggested (the combination of an anxiolytic is not systematic) effective dose (in the upper end of the range of Vidal) and for a sufficient time (at least two weeks).
For severe depression with major anxiety, it is possible to prescribe a kind SNRI venlafaxine (Effexor) at a dose of at least 200 mg / day. According to history (like episodes) and according to the etiology (event versus personality), the duration of the prescription of an antidepressant from 3 months to a year or more. It must be associated with psychological support, knowing that full depression, sensitivity to this action is low and that, in any event, it is insufficient, it is indeed the worst time to undertake psychotherapy analytical inspiration.
Should hospitalized for depression?
A psychiatric bed is not a bed nursing home, a hospital must be a goal that requires this form of care. Three circumstances are possible, in order of need: the risk of suicide, the expulsion of a depressogenic environment and failure of outpatient treatment behaved well.
Suicide risk:
In this regard, the recommendations were recently released by the HAS (High Authority of Health, April 2005) regarding hospitalization without consent: a hospital on the request of one third (HDT) must be indicated before a suicidal crisis ” high urgency “, that is to say, according to the hAS for a patient:
– Decided; whose passage to the act is planned and scheduled for the following day;
– Completely immobilized by depression or in a state of great agitation;
– Including pain and mental suffering are ubiquitous or completely silenced;
– Having a direct and immediate access to a means of suicide (drugs, firearms, etc.);
– Having the feeling of having done everything and tried everything;
– Very isolated.
Need a break in the middle:
Whatever the effectiveness of antidepressants, it is constrained by the environment if it is objectively the main cause of depression. Whether the professional environment (with the famous bullying), family or lack thereof, torque, etc., all these situations require extracting the patient context in which it evolves with the vulnerability induced its state.
Failure of outpatient treatment:
We speak of failure if at least two antidepressants from different mode of action were prescribed sequentially in dosage and duration sufficient. The statement of the hospital is always based on the patient’s clinical condition but also a therapeutic project likely to raise this resistance: continuous, higher drug dosage, multidisciplinary approach, possible use of methods such as electroconvulsive therapy.
Should we ask the “100%”?
The decree of 4 October 2004 (No. 2004-1049) changed the criteria for exemption from co-payments for psychiatric disorders.
These new exclusively medical criteria are more specific for depression, and they are binding as they appear in full in the Annex to Decree. PIRES when writing the protocol, the physician must meet 3 orders of medical criteria:
– Diagnosis: established according to the list and criteria of ICD 10;
– Seniority of affection: at least one year at the time of application; the functional consequences in the cognitive, emotional and behavioral consequences that must be major and directly related to the condition. This is to describe the handicap created by it in daily life.
Regarding diagnosis, the decree includes a section devoted to “disorders of persistent or recurrent mood.” It is stated:
– Bipolar disorder (manic-depressive illness);
– Recurrent depressive disorder (after three episodes at least);
– Disorders of persistent and severe mood.
Excludes: isolated depressive episode, brief depressive reaction, acute reaction to a stressor and mild dysthymia.
TO CONCLUDE:
By appropriating the diagnosis of depression, our company has not blithely between sadness and depression.Amalgam is done, and it is a source of ignorance of real depressions and medicalization of sadness.
This diagnosis is difficult to focus on oneself, implies observation and rigorous reasoning, two qualities to medicine. It is based on criteria which subjectivity can be reduced by the examination method “interactive” proposed, based on the detection of a change, a break, a collapse that characterize entering a real depressed state. The diagnosis is carried, to behave resulting order is “bio-psycho-social” in that face depression, an antidepressant is necessary and even indispensable, but insufficient. Depression is the leading cause of suicide is one of the main causes of death for certain age groups. From this point of view, the confusion between sadness and depression is no longer a simple semantic shift.
