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ⅥDepression

Depression in the Prime of Life —Its Characteristics and Precautions —Required in Treatment—

JMAJ 44(5): 221–224, 2001

Tetsuya HIROSE

Professor, Department of Psychiatry, Teikyo University School of

Abstract: Depression may occur at any age, but that occurring in the prime of life (maturity) is considered most typical, given its symptoms, course, and other aspects of serving as a prototypic model. The 3 major depressive symptoms of depressive mood, retardation, and are often observed to the same extent, demon- strating a stable cycle in mature depression. Attention should be paid, however, to the onset of hypomania because some patients end up as rapid cyclers alternately repeating manic and depressive episodes. This disease often occurs in those with melancholic personality who are scrupulous and have a strong sense of obligation and responsibility when encountering change such as career changes, or may often occur in postpartum depression. Even though endocrine changes should be consid- ered in the latter, it is helpful to handle these cases as attributable to the entangle- ment of character and circumstance. Pharmacotherapy is most effective against depression in this generation. Unlike elderly patients, serious adverse reactions rarely occur, but, it is essential to administer sufficient , etc., for a long enough time. Mood stabilizers are also required in the treatment of bipolar II disorder. Key words: Mature depression; Typical symptoms; Melancholic personality; Antidepressants; Hypomanic state

Introduction often occurs for the first time in those in their late 20s to 30s. Depression is thus considered While is regarded as a disease as a disease typically occurring in the prime of of adolescence, depression is characterized by life. While childhood, adolescent, and geriatric initial onset and recurrence at any age. While depression mostly demonstrates specific types, manic depressive illness or depression in the prime of life occurs as a onset ranges from the second half of the teens “prototype”, meaning that basic symptoms of to the first half of the 20s, unipolar depression depression are all present.

This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol. 124 No. 1, 2000, pages 49–51).

JMAJ, May 2001—Vol. 44, No. 5 221 T. HIROSE

Dependence Sleep disorder Lachrimosity Avoiding being alone Abnormal Headache & Vertigo sensation dull headache Downheartedness Tinnitus Excessive worry Neck pain & Pessimistic thoughts stiff shoulders Hypochondria Inferiority complex (Loneliness) Anorexia Perspiration Depressed Thirst Palpitation mood & Feeling of Loss of confidence Anxiety, vomiting Fatigue, respiratory irritability Afraid to go difficulty to work Feeling of Easy fatigability Lethargy Easy gastric discomfort Chest pain Regret fatigability Malaise Constipation (tendency to Diurnal & diarrhea Back pain & Self-blame variation lie still) Decreased body lumbago Suicidal wish Misanthropy weight Arthralgia Retardation Pain in the (Inhibition) Decreased efficiency extremities Decreased sexual desire Untidiness Poor concentration Sexual dysfunction Decreased interest Abnormal menstruation Decreased decision-making function Pollakisuria

Fig. 1 Symptomatic spectrum of depression Fig. 2 Physical symptoms of depression

Characteristics of Depression in the depression, so it is possible for friends and Prime of Life colleagues to suspect depression if a person becomes aloof. 1. Symptomatology Unlike geriatric depression, delusion is Retardation is often conspicuous in depres- observed less in mature depression but self- sive patients in their 20s, whereas elderly blame occurs frequently and a small failure patients tend to show anxiety and agitation. at work or slight scolding by a superior may Mature depression (depression in the prime have an excessive impact on the patient, even of life) is positioned in between and char- triggering suicidal tendencies. Many acterized by 3 major psychic symptoms— cases associated with corporate restructuring depressive mood, retardation, and anxiety are assumed attributable to self-blame and (Fig. 1). Mood is a subjective matter and not despair related to depression. always expressed accurately. In women, mood In addition to psychic symptoms, physical is expressed in objective symptoms such as symptoms are associated with depression. lachrimosity. The onset of depression may in which psychic symp- often be detected when the patient hangs toms are inconspicuous while physical symp- around and follows someone close to the toms are noted in the foreground is a well- patient due to loneliness and anxiety. Strong known case. Typical masked depression is anxiety leads to agitation or panic attacks, but most frequently observed in mature depres- the disease is an abnormality in thought such sion. Extensive physical symptoms are noted as excessive concern or worry in less serious but central symptoms classified as systemic are cases. Added to a depressive mood, pessimis- general malaise and fatigue resulting in tic thoughts and loss of confidence occur. attempts to lie down whenever possible. The Retardation tires the patient, causing a loss influence of retardation, a psychic symptom, of interest and decreased communication. should be considered (Fig. 2). These symptoms all impact on a person nor- Considering physical symptoms accompany- mally sociable, consequently causing misan- ing general malaise and fatigue, a physical dis- thropy. Such a tendency is observed in initial ease is first suspected by a physician, but the

222 JMAJ, May 2001—Vol. 44, No. 5 TYPICAL DEPRESSION

presence of insomnia, which persists from the men, mostly salaried men, increased responsi- initial stage of disease and even after other bility due to transfer or promotion may be a symptoms have been resolved and diurnal precipitating factor. Those with the above per- variation may give a clue to the diagnosis of sonality adapt to an environment in which depression rather than physical disease. they set their pace of work as in the case of Psychosomatic disease such as peptic ulcer crafts people but are vulnerable to stress in an may occurs prior to the onset of depression. environment of change, increased workload, The syndrome shift is acknowledged between requiring resources in an emergency, often depression and psychosomatic disease, espe- resulting in the onset of depression. Women, cially in mature depression. In other words, also susceptible to changes, may develop so- a psychosomatic disease should be regarded called house-moving depression. Postpartum as a warning sign of depression in mature depression can occur in this period and in the depression. 20s. Although physical factors including change in the endocrine system due to preg- 2. Course nancy and delivery may play a role in onset in Depression is likely to recur. And has clini- most cases, the illness is associated with the cal importance in treatment. Compared to character of a person who cannot withstand other ages, intervals between episodes are change or cope with mother role and environ- relatively long in mature depression in gen- mental factors. eral, indicating a stable cycle. Attention should be paid, however, to patients demon- 4. Comorbidity strating unstable elements because those long Unlike geriatric depression, comorbidity assumed to have unipolar depression may sud- with physical disease are characteristically less denly demonstrate a hypomanic episode after common in mature depression. Attention several repetitions of depressive episodes. should be paid, however, to panic disorder Some shift to rapid cycling, turning into fre- and dependence as psychiatric comor- quent manic-depression episodes, while others bidity. Panic is frequently noted in women in demonstrate so-called bipolar II type in which their 30s and observed depressive episodes and hypomanic episodes more in men in their 40s and 50s, but it should are alternated. be remembered that these disorders occur in Seasonal depression is another depression both men and women. If treatment focuses related to maturity. Occurring from autumn on panic disorder and anxiety neurosis just to winter and showing sign of remission because panic attacks are conspicuous, coex- or hypomania in spring. This is frequently isting depression may be overlooked. Alcohol- observed in women and is dealt with specifi- ism is primary in some cases and secondary in cally treatments as described below. others, and it is possible to dissipate alcohol dependence by appropriately treating depres- 3. Premorbid personality and precipitating sion. The risk of suicide is higher than in those 3. factors with depression alone, so care should be Completion of a melancholic type character- taken. ized by scrupulosity, perfectionism, a strong sense of obligation, responsibility, and exces- Precautions in Treatment sive consideration for others is observed in this period, and typical depression in this period of 1. Pharmacotherapy life occurs, triggered through entanglement of Many with such mature depression are this personality and environmental factors. In classified into endogenous depression and

JMAJ, May 2001—Vol. 44, No. 5 223 T. HIROSE

respond favorably to pharmacotherapy. In they are easily ravaged. Psychological educa- comparison to elderly patients, adverse reac- tion explaining the nature of disease is indis- tions are not so serious and the need to pay pensable both for the patient and family. It is attention to comorbid physical diseases is less. especially important to obtain full understand- In principle, tricyclic antidepressants, consid- ing of the spouse because any harsh words ered effective against moderate or severe from the spouse may have fatal consequences depression, should be administered at suffi- in the patient. In remission, cognitive therapy cient doses and for several months after correcting the scrupulous and perfectionistic improvement is noted. , clomipra- personality or extreme thoughts is conducted mine, , and are the to prevent recurrence. drugs of choice. Tetracyclic antidepressants, which are somewhat less effective than tricy- Conclusion clic ones but which cause less adverse reac- tions, are administered to outpatients with Depression in the prime of life is charac- mild symptoms. Drugs other than tricyclic terized by a stable cycle. Symptomatically, ones frequently prescribed are , depressive mood, retardation, and anxiety , , trazodone, sulpiride, are typical. As patients respond more favor- and fluvoxamine. ably to antidepressants without serious Since treatment with an adverse reactions, treatment at a sufficient makes course more unstable in bipolar II dose for a sufficient period leads to a favor- patients who demonstrates hypomania, mood able outcome. It is necessary to use mood sta- stabilizers including , , bilizers in hypomania. Along with supportive and sodium valproate constitute mainstream psychotherapy, psychological education and treatment, and antidepressants are used as family support are indispensable to successful needed. The efficacy of phototherapy exposing treatment. the patient to full spectrum light is known to be effective against seasonal affective disorder. REFERENCES

1) Akiskal, H.S.: Mood disorders: Clinical fea- 2. Psychotherapy tures. In: (Sadock, B.J., Sadock, V.A. eds.) Although treatment centers on pharmaco- Kaplan & Sadock’s Comprehensive Textbook therapy, psychotherapy is also indispensable. of Psychiatry, Seventh edition. p.1338–1377, The principle that encouragement for depres- Williams & Wilkins, Philadelphia, 2000. sive patients is a taboo is well known to 2) Rush, A.J.: Mood disorders: Treatment of the public. The supportive psychotherapy for depression. In: ibid. p.1377–1385. depressive patients who suffer from loss of 3) American Psychiatric Association: Diagnos- confidence, anxiety, and pessimistic thoughts tic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV). APA, Washington literally supports and prevents them from DC, 1994. going into a vicious circle of depression, and 4) American Psychiatric Association: Practice gives them a chance to rise to the baseline. Guidelines for the Treatment of Psychiatric Positive family support is also needed, espe- Disorders, Compendium 2000. APA, Wash- cially by the spouse of the patient, because ington DC, 2000.

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