Dr. K. M. Dhawale
M.D.; D.P.M.; M.F.Hom. (Lond.)
Principal, Dr. M. L. Dhawale Memorial Homoeopathic Institute, Mumbai
Depression as an illness is one of the leading disorders likely to afflict mankind in the coming decades. In fact, some estimates have placed it to be the second-most common condition amongst our Outpatients by 2020. The lifetime risk for developing Major Depression is estimated at 7% to 12% for men, and a phenomenal 20% to 25% for women! The risk of recurrence is about 70% at 5-year follow up and at least 80% at 8-year follow-up. 25% of individuals with severe, chronic medical illness (e.g., diabetes, myocardial infarction, carcinomas, and stroke) develop depression.
Homoeopaths are and will be required to deal with this entity increasingly as it will be frequently encountered in the clinics. Patients are also unhappy with the limitations of the current psychotropic medication in being unable to prevent recurrences and the frequent side effects with prolonged use. Hence it is essential for us to acquire sensitivity to receive the depressive, spot the common presentations and devise a management plan based on a holistic assessment of the patient in his environment.
- WHAT DOES A HOMOEOPATH NEEDS TO DO TO SUCESSFULLY MANAGE DEPRESSION?
A Homoeopathic physician needs to acquire a working knowledge in the following areas:
- Enhance clinical understanding of depressive disorders seen in Homoeopathic clinical practice.
- Correlate the clinical approach to depression with Homoeopathic principles as laid down by Hahnemann and other stalwarts.
- Deepen the awareness of the Homoeopathic physician of his role in the diagnosis and management of depression.
- Appreciate the role and scope of currently available treatments for depression in Clinical Psychiatry and appreciate their influence in altering the susceptibility.
- Evolve a standardized approach to the understanding and treatment of depression.
- Improve awareness of the ancillary measures found effective in the treatment of depression.
- UNDERSTANDING AND MANAGING DEPRESSION
The Homoeopath should attend to the following areas:
- CLINICAL APPROACH
We now know that Depression can be a mood, a syndrome or a disease. The implication of each of these assessments is different. A mood is a passing phenomenon and may only need some support. A syndrome may need further investigation since we know that certain illnesses may present themselves as depression like hypothyroid conditions. It is only the disease that we are referring to in the opening paragraphs and which would need our medical attention.
Does Depression have a cause within the individual? Or is it inflicted on the individual by an unfeeling, insensitive environment? Are there periods in History where people are prone to suffering from Depression?
Certain temperaments are prone to depression? Hippocrates held the contention that there is an excess of ‘black bile’ in patients who develop this disorder. We do speak of a depressive diathesis. These tendencies are inherited. We see melancholic personalities as well as those who develop a negative perception of events rather easily. We also know from the works of the likes of Bowlby that losses in early life predispose to depressions in later age. The theme of loss dominates all concepts of depression. Loss (of people, money or even name!) occurring in later life tends to act more potently in such people.
Some depressions are certainly biologically based where the role of biogenic amines and neuroendocrine factors are crucial. In the northern hemisphere, the seasonal depressions are fairly common.
It is not always easy to diagnose Depression. The classic depressive triad of low mood, low energy and difficulty in thinking demonstrates how pervasive an illness it is affecting the mind and the body as a whole. But at times, the patient may not report these symptoms as clearly as we would think. We would be seeing a lot of anxiety and irritability as well. The clinician needs to be especially alert when she fails to decipher any underlying illness in a patient with multiple somatic symptoms. These are patients with masked depression.
Is it important that we do not miss to diagnose Depression in the presence of other Medical disorders. The implications of the missed diagnosis could be grave as it has been proved that the underlying medical condition gets accelerated in the presence of depression and deaths are more frequent in cardiovascular conditions when depression goes untreated.
- HOMOEOPATHIC APPROACH
We must understand that Depression from the perspective of Homoeopathic philosophy may be considered as a Constitutional disorder. The whole system of man participates in the illness and we generally encounter symptoms in all the spheres viz. mental, generals and particulars. Hence case taking acquires paramount importance. An accurate family background with evidence of early childhood deprivations can often be unearthed with the greatest difficulty since the ease of communication can be hampered greatly due to the low mood. One might have to rely on the account of the close family members if they are available to supplement the history.
Observations will not only enable an assessment of the severity of the illness but may also point to certain characteristics e.g. pronounced debility with the mood disturbances. As is evidenced from the above discussion, pertinent investigations will acquire data in the following categories:
- Causation- A.F. usually emotional but may also be intellectual and rarely physical especially when we discern suppression in the etiology
- Aggravations – again these are usually emotional causes depending upon the general sensitivities of the individual. Intellectual and physical modalities are not uncommon as is seen in diurnal or seasonal variations.
- Mentals appear to be of great importance but it would surprise us to actually find not much of utility since most of the symptoms are common symptoms of depression. Deriving ‘Qualified Mentals’ from these is not very easy. And including the common symptoms of depression does not point to the similimum.
- Physical generals and particulars as concomitants will give us a hold on the case. Hence it is always valuable to define the associated complaints in some detail. As indicated above, depression will exacerbate the march of chronic disease. That is also a good reason to keep these complaints under the scanner and ensure that the disease does not progress.
The clinical distinction between Major Depression and Dysthymia should be always borne in mind. While the former is generally severe and may result in attempts to end life, the symptoms of the latter are more troublesome for both!
Is there any role for Miasmatic understanding in the treatment of Depressive disorders? Certainly, depression being a multifactorial illness, miasmatic factors will play a significant role. Fundamental miasm should be investigated in detail since it is likely to drive the dominant miasm and that may be for the worse. Hence the clinician should look out for syphilitic activity.
One will readily see that Kentian method of repertorization will be commonly found useful. But as adduced above, Boenninghausen’s contribution should not be forgotten as we may be able to get strong physical generals but weak mentals. Occasionally, a phasic remedy may also serve to open the case and relieve the acute distress. The physician should remain alert to the changing totality and be ready to switch forces from the phasic to the deeper constitutional as that alone will serve as a curative force as well as preventive one. We should always remind ourselves that Depression is a periodic, chronic illness. .
There is a definite role for remedial and non-remedial measures in the Management of Depression. This has been clear even to Hahnemann when he wrote of the need for managing mental illness in the Aphorisms 210-230.
The first dictum in the management of a depressed patient is assessing his suicidal status and taking adequate care of this risk. Keeping the close ones informed about the danger, ensuring that the patient is never alone, and a close monitoring of the mood state is mandatory if the risks have to be reduced.
We have already mentioned the preferred homoeopathic approach to the management through the employment of the Constitutional remedy. At times, based on the acute nature of the totality, a phase remedy could be indicated. In cases of acute depression where suicide is a risk, this is often desirable. An antimiasmatic intercurrent is rarely employed when the miasmatic basis is fairly strong and the indicated remedy is not able to give sustained relief.
Susceptibility when assessed is generally assessed as high. Hence the higher potencies are needed to bring early relief. Infrequent repetition with an objective of bringing about a change in the entire picture of depressive symptoms is expected. Thus a weekly and thereafter fortnightly follow up should indicate a reduction in subjective distress (sleep loss, anxiety-depression, and vegetative symptoms like appetite, bowel movements, etc. should show a uniform change. That alone will convince us that we are on the right track. Presence of concomitant symptoms is important as it helps to track the general progress and significant relief here enhances the confidence of the physician in the choice of the remedy.
When may one stop administering the remedy in order to prevent a recurrence to which some patients are prone? There is no easy answer to this question. Seeking a good understanding of the patient with the environment and helping his coping abilities to improve through the employment of non-remedial measures (see below) is necessary. Alerting the patient to the likelihood of recurrence and assuring of early intervention to prevent the full blown picture is of course essential. And indeed, experience has shown that administering the remedy in the early evolving phase of depression does ‘abort’ the progress and we are able to claim a good result.
A vexing question remains: What does one do with the allopathic drugs which may already be prescribed by the psychiatrist? Can we start treatment simultaneously with our remedies? One should never interfere with the prescribed drugs under any circumstances. In fact, often the side effects may be the ones that bring the patient to the homoeopath. A healthy dialogue with the psychiatrist is the ideal answer wherein we inform the psychiatrist of what we can offer. Most of the times, the beneficial effects are seen early and the psychiatrist on his own do reduce the dosage and gradually taper them down. A small maintenance dose is generally left which does not really interfere with the actions of our medicines. The patient is the best judge of the situation.
A number of non-remedial measures are available for the management of Depression. The homoeopath may not be familiar with their operational use but ought to have a knowledge of the types that have been found to be useful. Cognitive behaviour therapies (CBT) and Rational Emotive therapies (RET) are found to be the most effective especially when one is wishing to improve the coping abilities and working to prevent recurrences.
Along with this, an assessment of the environmental stressors (which the homoeopath has already done in the course of the case taking) will give the areas where external change may be advised. Some of these may not be in the scope of a physician e.g. unemployment. But it does help to become aware of these stresses and making the patient aware of the need to consider action on these fronts.
Case No 1 (Contributed by Dr. Anand Kapse, Vice principal, MLDMHI)
Mr. N. L., a 33 year old businessman reported on the 17th January 1997 with symptoms of depression since 2 months consequent to financial loss as a result of dissolution of business partnership. The symptoms comprised of loss of confidence, inertia, weeping spells, desire to be alone with sleeplessness and reduced sexual desire. He was also having headaches and palpitations. Since the last 15 days, he had reported a loss of appetite and weight loss.
A similar episode had occurred in 1992 and 1994. He had been hospitalized for the first episode as he had suicidal ideas. This too was precipitated by financial strain where he had borrowed money and was unable to pay in time.
The current episode was brought about by his allegation that his partner cheated him and then spread lies about his financial irregularity. This was a severe loss to his reputation.
The patient has always been a carefree person and has been deeply attached to his mother. Being the youngest of three brothers, he felt that it was his responsibility to look after his parents. However, there were differences between his wife and mother which led to ‘they being kicked out of the home by the mother’ as per his words. That was a severe blow to him. Now his mother is having health problems and he feels that he is needed by her side but does not feel free to return.
He has been exploring a number of businesses from time to time and is never wanting in due diligence. He strives to adhere to good business norms but finds that other persons take advantage of his ‘goodness’.
Appearance: Depressed face with angle of lips turned downwards
Cr: COLD DRINKS, MILK SHAKES, ICE CREAMS, COLD FOOD, SWEETS
Sexual Function: H/o = N, decreased since Dec 96
He is chilly. Wants to cover head from draft
The patient is suffering from a Recurrent Major depressive disorder and this appears to be the third episode. He appears to be an upright individual and sensitive to loss of reputation. He has a high sense of duty and responsibility and is basically a family oriented person. There is evidence that he had suicidal ideas.
The Kentian method of repertorization was found appropriate.
Company Aversion to
Desire: Cold Drinks, Cold Food, Ice cream, Sweet
Cold air head sensitive to
The remedies indicated were Aur met (20/5), Nat mur (13/4), Ignatia (12/4).
Aurum met in 1M potency was administered and the patient showed a good response in three days. He needed three more doses to recover completely. Later, he wound his business, realized that his temperament was not suited for doing business and took up a job in Dubai. He moved his family there and did not suffer from an attack of depression for at least 5 years thereafter.
The case illustrates the need to understand the disposition of the patient which predisposes to the development of depression and how a single dose of the similimum will help in the right potency. It also demonstrates the need to pay attention to risk factors which in this case was the business environment which was clashing with his value laden principles. His recurrent attacks disappeared once he changed this environment and was out of the conflict zone.
Case No 2
A 45 year old married female was referred by a psychiatrist who was treating her for recurrent attacks of depression. However, the tendency to relapse was not in control.
The peculiarity of her attacks comprised of the manner in which these episodes would begin. She used to complain of a sensation of burning in legs which used to ascend upwards. This used to make her miserable and she would be agitated, sleepless, irritable, weepy and anxious. She had trembling of limbs, palpitations and often expressed her desire to do away with her life. She had lost 20 Kg in the last two years. The local physician used to treat her until one day her neighbor physiotherapist felt that the patient was depressed and referred her to the psychiatrist.
She received antidepressants and used to respond but the frequency of attacks did not abated. She reported to me in her 5th attack.
She was an anxious person and was prone to worry about trifles. Being very emotional, she was unable to see any suffering around her. She also faced a lot of difficulty in adjusting to her married home. The husband was largely busy with his work and did not have enough time to devote to her. There were also differences over her spending pattern and she always faced money shortages. She was unable to get along with her neighbours and wished to change her residence. This not being an easy thing added yet another conflicting issue in marriage.
She was a hot patient. Aversion to meat was marked.
On examination her BP was raised. 150/100.
This was another case of recurrent depression but the presentation was through the somatic complaints. The burning pains were characteristic and these need to be incorporated in the totality. The anxious disposition and the irritable nature completed the picture of Kali sulph which was administered in the 200th potency.
Patient was on antidepressants and she was advised to continue these for the time being. However, the patient felt so much relieved with the similimum that she reduced the medication on her own. On the next visit, her BP had also reduced. The extraordinary aspect of the story was a year later when she returned for the onset of the depression through the symptom of burning pains. She had not as yet developed the mental symptoms. Kali sulph 1M administered took care of the pains and the full scale depression never developed.
This case shows the need to take care of the characteristic symptoms at the physical level while prescribing for a mental condition. (Frank Bodman had mentioned the fairly common occurrence of this condition in homoeopathic prescribing). It also shows how the administration of the similimum is able to abort the development of the attack. Incidentally, the holistic nature of the healing will also become apparent after it is seen that the Blood pressure also responded simultaneously.
A word of caution: The patient on her own discontinued the antidepressant medication and luckily did not go through any withdrawal effects. This is not a very usual occurrence. We should take care to caution the patient to seek the advice of the treating psychiatrist before changing the dosage of the allopathic medicines.