Historical Perspective

Depression has been recognized as a mental illness since ancient times. The earliest written accounts of what is now known as depression appeared in the second millennium B.C.E. in Mesopotamia. In these writings, depression was discussed as a spiritual rather than a physical condition. Like other mental illnesses, it was believed to be caused by demonic possession. As such, it was dealt with by priests rather than physicians. The idea of depression being caused by demons and evil spirits has existed in many cultures, including those of the ancient Greeks, Romans, Babylonians, Chinese, and Egyptians. Because of this belief, it was often treated with methods such as beatings, physical restraint, and starvation in an attempt to drive the demons out. While many believed that demons were the root cause of depression, there were a number of ancient Greek and Roman doctors who believed that depression was a biological and psychological illness. The concept of depression has similarities with the much older concept of melancholia. The term melancholia is derived from the Greek words “melas” meaning black and “khole” meaning bile, one of the four humours postulated by Galen. Greek and Roman doctors used therapeutic methods such as gymnastics, massage, diet, music, baths, and a medication containing poppy extract and donkey’s milk to treat their patients ¹, ², ³.

The term major depressive disorder (MDD) was first introduced by clinicians in the United States during the 1970s. The condition officially became part of the DSM-III in 1980. The current edition of the diagnostic manual is the DSM-5 and is one of the primary tools used in the diagnosis of depressive disorders⁴.

Prevalence
Major depressive disorder (MDD) is a common psychiatric disorder that affects millions of people worldwide. According to a systematic review, the lifetime prevalence of MDD ranged from 2% to 21%, with the highest rates found in some European countries and the lowest in some Asian countries⁵. In Nepal, the prevalence of MDD is estimated to be around 15%⁵.

Symptoms
MDD is characterized by persistent sadness, loss of interest or pleasure, low energy, worse appetite and sleep, and even suicide, disrupting daily activities and psychosocial functions¹. Other symptoms include feelings of worthlessness, guilt, hopelessness, and helplessness.

Diagnosis
The diagnosis of MDD is based on the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) . The DSM-5 criteria require the presence of at least five of the following symptoms for at least two weeks: depressed mood, loss of interest or pleasure, significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate, and recurrent thoughts of death or suicide⁶.

Etiology
The exact etiology of depression is yet to be understood fully. Etiology of MDD is widely believed to be multifactorial, involving social, psychological, and biological aspects. Childhood trauma, stressful life events, and chronic physical conditions are also associated with MDD.

Psychological Management
Psychotherapy is an effective treatment for MDD ¹. Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy (PST) are some of the most commonly used psychotherapeutic approaches for MDD ¹.

Pharmacological Management
Antidepressants are the first-line treatment for MDD. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the most commonly used antidepressants. In Nepal, the availability of antidepressants is limited, and their use is often associated with stigma.

References: 

1. When Were the Earliest Accounts of Depression? Verywell Mind. Accessed November 22, 2023.             https://www.verywellmind.com/who-discovered-depression-1066770

2. Haenel T. [Historical notes on the therapy of depression]. Schweiz Med Wochenschr. 1986;116(47):1652-1659.
3. Schildkraut JJ. The catecholamine hypothesis of affective disorders: a review of supporting evidence. Am J Psychiatry. 1965;122(5):509-522.
4. When Were the Earliest Accounts of Depression? Verywell Mind. Accessed November 22, 2023. https://www.verywellmind.com/who-discovered-depression-1066770
5. Horwitz AV, Wakefield JC, Lorenzo-Luaces L. History of Depression. In: DeRubeis RJ, Strunk DR, eds. The Oxford Handbook of Mood Disorders. Oxford University Press; 2017:0. doi:10.1093/oxfordhb/9780199973965.013.2
6. Tolentino JC, Schmidt SL. DSM-5 Criteria and Depression Severity: Implications for Clinical Practice. Front Psychiatry. 2018;9. Accessed November 22, 2023. https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00450