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(Article published in HomeoBuzz, Feb. 2010)

It is very easy to diagnose AIDS, Cancer, Tuberculosis or any such diseases by correlating the clinical findings with the investigation reports. On the other hand, diagnosing a psychiatric case is not that easy. Hence, most of the psychiatric patients are either wrongly diagnosed or over-diagnosed as “madness”. A person with a history of major somatic illness when gets cured will be well accepted by the society, whereas a person with a history of psychiatric disease may not be accepted fully. But the fact is, it is very difficult to find out a person who has not had an emotional outbreak at least once in his lifetime. Suppose our beloved one is attacked by somebody in front of us, we will be responding violently without thinking about the surroundings and our social positions, and a few among us may even forget the existing law. We may even behave like an insane at that particular moment as a result of sudden release of stress hormones like adrenalin, and once we come out of that situation, we come to the normal level. In that sense, there is a hidden madness in every human being!

Among the various psychiatric disorders, the most commonly affected one is depression. In common parlance, the depression implies a feeling of sadness or normal affect. Though in our repertories, the rubric 'Depression' is represented as 'sadness', depressive disorder is much deep seated than sadness. We all come across tragedies in our life in the form of death, loss of something or an emotional trauma, and it causes an impact on our mood, which is usually called blues. This is considered as a natural phenomenon, but gradually we get adjusted with the situation and we return to the normal level. Weeping is also a natural outlet that can ease the intensity of sadness. But those who cant overcome the grief, especially the pessimistic individuals, go into clinical depression and continue as major depression, or it can even go into psychotic depression. Once we overcome the acute emotional outbreak, most of us usually accept several adaptation techniques to overcome a depression, which may be religious practices, spirituality, social work etc. One the other hand, those who are already under the influence of a miasm go for substance abuse, suicide, homicide, sexual offenses etc.

If the sadness goes beyond a certain limit, it has to be managed scientifically. Some times, the family members of the patient may report the doctor that the intensity of his/her depression is not so severe and there is no significant reason for a depression, but only the victim can feel the intensity and the agony of his sufferings. Nowadays, treatment of depression is given much importance because those who are having less tolerance to stress, if do not get proper treatment, may end the life in suicide. Also there is an increase in cases wherein the person commits suicide at the time of facing a stressful situation, without giving a chance for treatment or any sort of natural adaptations.

Depression in psychiatry
Psychiatric diseases may be Organic psychiatric diseases, Substance abuse disorders and Functional psychiatric disorders. As the name indicates, organic psychiatric diseases are related with the diseases affecting the brain, other organs and systemic diseases. Substance use disorders are as a result of prolonged use of habit forming psychotropic substances. The functional psychiatric disorders comprise the major portion of the psychiatric cases in our day to day practice.

Functional psychiatric disorders may be:
Psychotic diseases like schizophrenia, schizotypal and other delusional disorders
Acute psychotic disorders
Mood disorders
Neurotic-stress related-Somatoform disorders
Behavioral syndromes associated with physiological and physical factors (eating, sex, sleep)
Disorders of personality and behavior

The depression and mania comes under Mood disorders. When the depression and mania occurs in the same individual on alternating episodes, it is diagnosed as Bipolar disease.

Causes of depression
Our mental and emotional features are influenced by genetic, neurobiological and environmental factors. Hence every human being respond differently to each life situation. One silly reason for most of us may be a major cause of depression for a sensitive individual. However an acute episode of depression is common in almost all human beings while facing a tragedy.

The causes of depression can be classified under the following headings:

Losing something
Death of loved ones, financial loss, loss of job, disappointed love, loss of social position, divorce, leaving away from the loved ones, impotency, infertility.

Influence of the situation
Job stress, business failure, poverty, unemployment, serious disease, physical disability, discords between family members, marital disharmony, natural calamities, loneliness.

Mental and emotional trauma
Insult and torturing, torture by in laws, dowry related stress, rape, incest, victim of cheating, guilty feelings due to previous sins and misdeeds.

Genetic and hormonal
Positive family history, hormonal imbalance (menarche, menses, pregnancy, delivery, unexpected pregnancy, perimenopausal depression, old age)

Drugs and treatment
Substance abuse, prescription drugs (steroids, contraceptive pills etc.), surgical menopause, amputation, mastectomy.

Clinical features
The clinical presentation of depression may vary among different age groups. However, certain mental symptoms are common among all victims.

Mental symptoms:
Emotional symptoms, unpleasant mood, loss of interest in surroundings, sadness, weeping tendency, irritability, fighting for silly reasons, quarrels with family members, aversion to go out, unexplained fear and anxiety, avoid people and responsibilities, loss of cheerfulness, restlessness, listless.

Isolated feeling, emptiness, lack of confidence, inferiority, life feel meaningless, forsaken feeling, suicidal thoughts, feel helpless, recurrent negative thoughts, guilty feeling, loathing of life.

Decrease in performance, impaired concentration &memory, poverty of ideas, psycho motor retardation, impaired skills, poor school performance.

Physical symptoms:

Tiredness, increased/decreased appetite, weight gain/loss, insomnia/hyperosmia, non specific aches and pains, headache, giddiness, palpitation, diminished sex drive, dyspnoea, dyspepsia, non specific abdominal pains, menstrual irregularities etc.

Classification of depression

An acute episode of sadness is usually self limiting and it may not affect the quality of life, hence it is not considered as a depressive disorder. A case presented with a significant clinical features of depression can be classified under the following headings.

Major depressive disorder: Here the affected person is unable to enjoy life because of deep seated depression. The symptoms are constant and last about six months. His mood is depressed throughout the day with diminished interest in any sort of activities. There is marked weight loss/gain and increased/decreased sleep. There is loss of energy and ability to think or concentrate on any sort of activities. He will be repeatedly hunted by a guilty feeling. The victim of major depression may be affected either by a single episode or by recurrent episodes.

Dysthymia: It is a type of mild depression with recurrence of symptoms. There is low self esteem, hopeless feeling with low energy levels. The appetite is either decreased or increased. Similarly, the sleep is also affected, which may be either insomnia or hypersomnia.

Seasonal affective disorder: This is a depressed mood that occurs during rainy days and dark cloudy weather. It is interesting to note that Hahnemann has understood the relationship between the environment and our mind, much earlier than the introduction of 'seasonal affective disorder' into the field of psychiatry.

Atypical manifestations of depression: This includes: Mixed states(presence of combination of bipolar and depression symptoms), Schizodepressive states(presence of symptoms of schizophrenia), Depersonalisation (occurs secondary to high level of anxiety), Excessive drinking (alcohol gives euphoria but cause depression later), Suicidal idiation (thoughts about suicide), Homicidal attack (kill the spouse and children and commit suicide).

Bipolar disease: Alternating episodes of depression and mania.

Cyclothymia: It is a mild form of bipolar disorder.

Psychotic depression: Depression with hallucinations, delusions and loss of touch with the reality.

Differential Diagnosis

Depression should be differentiated from Somatic depression, Schizophrenia, Bipolar disease, Substance abuse, Adjustment disorder, Anxiety neurosis, Manic depression, Post traumatic stress disorder etc. Some times, the neurosis and psychosis cases may also come with some features of a depressive disorder, which can lead to diagnostic dilemma. It may be easy to differentiate neurosis and psychosis. A neurotic person will always say that he has some mental disease, but his family members will say that he is alright. Whereas, a psychotic person may tell that he is mentally perfect, but others usually complain that he is psychic.

Hahnemann was the first one to open a real mental asylum, because in those days lunatic asylums were attached with the jails and the psychiatric patients were brutally treated as criminals or victims of evil spirits. Hahnemann could make out the fact that the crude preparations of drugs can only suppress the symptoms and the patients come up with more serious health problems in the near future. His holistic approach through the application of a humane mode of treatment opened a new era in the history of psychiatry. Hahnemann's classification of mental diseases into four different types is also very unique. He was one among those physicians who proposed that mentally ill patients are sick individuals and they require empathy and medical care. Through his writings, he emphasized the importance of psoric drug therapy and psychotherapy in the management of mental disorders.

Practically, we can classify the cases of depression into two category. The first category of patient comes for the treatment of depression and the other one comes with other somatic symptoms, without expressing the symptoms of depression. The patients among the second group may hide the symptoms because they don't want to be called as psychic, hence interaction with the family member is a must in such cases. We should also take some precautions while dealing with such patients. During the first consultation itself, if we tell the patient that he has some mental disorder, he may get embarrassed and may leave the treatment. Whatever the feelings and ideas the patient tells us should be noted down using the same words, and we should not try to correct his false believes while taking the case, because such approach may make the patient uncomfortable. Correcting his mistakes and giving suggestion should be done only after doing the disease and remedial diagnosis. Hence it is the art of the physician to dig out the hidden symptoms that are vital for the selection of a remedy.

While repertorizing, do not consider the main rubric 'sadness' (Many drugs are given), try to qualify the symptoms and go for a sub rubric. By exact observation and interpretation, we should consider other main rubrics such as brooding, dejection, despair, despondency, discouraged, dwells on past, forebodings, gloomy, grief, hopeless, inconsolable, low spirited, sighing, sorrowful, weeping etc. In psychiatric cases, some mental symptoms may be the common symptom of a particular disease, in such cases the physical generals and other characteristics are more important.

As homeopaths, prime importance should be given to the application of the similimum in suitable potency and dose. Apart from that, counseling, psychotherapy, cognitive therapy, behavioral therapy etc are needed. Application of mind relaxing techniques like Yoga, Meditation, Breathing exercises etc. are also beneficial. An attempt should be made to remove the maintaining cause of depression such as suggesting a suitable job if unemployment or job stress is responsible for the depression.

The treatment will be easy if there is a known cause for the depression with a sudden onset . Similarly prognosis is good if there is no family history and history of substance abuse. Apart from that, support from the family is very essential. The outcome of treatment also depends upon the maintenance of a tension free atmosphere.

A case of depression (OP. No:96, Dated: 21-7-2003)
Mr M, 40, an ex business man consulted me for earache since a few days. The complaints started after an early morning river bathing performed during a pilgrimage. He had also exposed to cold wind several nights throughout the journey. A few doses of Mag phos 30 and Kali Mur 3x cured his earache completely.

He again consulted me along with his wife after a few days. This time, his situation was totally different from the previous visit. That time, though he had severe earache, his facial expression was not that dull, but now he looks very dull and I felt he was very shy to tell his problems, hence I doubted whether my first prescription has acted in a wrong way. He prompted his wife to tell the complaints and kept silent. Finally she told his history in detail.

He was the regional distributor of a famous pharmaceutical company. He was a very dedicated and sincere person. When his business flourished he felt difficulty in the management, hence he appointed some of his cousins as his assistants. With their support his business became well established and opened several branches, but he had to face some issues related with the bank loan and some tax problems. Following the advice given by his cousins and the tax consultant, he distributed the ownership of his properties among his cousins. Later, with a great shock to the whole family, he came to know that it was a foul play made by his cousins in order to seize his properties. Though he had solid evidence against them, he didn't proceed legally with a hope that God will teach them a lesson, and continued his own business. But his cousins became his main competitor and finally they took the distribution-ship of the same company. After that incident, he had to do his business with some local made products, but he could not continue due to heavy liabilities left behind by the previous business.

He lost his properties and since then he lives in a rented house with his wife and children. Since he hates violence and the consequences of filing a case, he kept silent. Now he does nothing and his only income is some financial support from his in-laws.

After this incident he became very much depressed and lost interest in life. He even lost faith in God. Due to constant pressure from the wife, he had agreed to consult a psychiatrist, but his medicines made him more weak and also caused acidity. Hence he discontinued the treatment. He preferred to be at home and took no interest to go out and mingle with the public. He avoided even his close relatives and friends. He became very slow and lazy in performing his day to day activities. His body weight got doubled due to inactivity. Since he lost his daily routines, he developed some gastric troubles and constipation. He had no bad habits and he preferred cold climate.

Initially he was interested in spirituality and reading, but lost interest after this incident. He felt very bad when others advised him to work somewhere. His changed character also affected his wife, and also his children, who lost interest in studies. Due to constant pressure from the wife, he agreed to go for a pilgrimage to a number of places, but had to discontinue the journey due to earache and consulted me. When his earache got relieved with my prescription, they decided to consult me for his mental problems which he didn't disclose during the first visit.

Considering the causation and the generals I prescribed Ambra G 200 one dose along with placebo and asked him to consult me after one month. Since he was interested in reading, I also suggested him to read a book “How to Stop Worrying and Start Living” by Dale Carnegie.

He came back with a smiling face and reported improvement in his mentality. But his financial status was getting very poor due to unemployment. I repeated the same medicine and advised him to do some small scale business or at least search for a job outside so that the maintaining cause can be removed. Though he was feeling bad to work under somebody, finally he got a job in a drug distributing company. After that he consulted me several times reporting good improvement and I continued the placebo, but suddenly he stopped coming. After a few month, he came to me with his co-worker and requested me “Doctor, my friend is also a victim of depression, please give the same medicine you had given to cure me”.

Compared to other schools of medicines, homeopathy gives more importance to symptoms belonging to mental and emotional spheres, and we go much deeper in to the life space investigation of the individual. In spite of all these unique qualities we have, the homeopathic psychiatry is not well developed as it deserved to be. It may be due to lack of awareness, poor infrastructure, and improper application of our system. True that we may not be able to handle some psychiatric emergency cases, but, with cent percent confidence we can say that our medicines act far better than the latest antidepressants and anxiolytic drugs.

API text book of medicine
Differential diagnosis by L C Gupta

Dr Muhammed Rafeeque
Family Homoeopathic clinic

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