Rheumatic fever is an inflammatory disease that is developed due to an infection caused with streptococcus bacteria. The infection is usually known as scarlet fever or strep throat. The joints, heart, brain and skin can be affected by this disease. There are many causes and risk factors of rheumatic fever.

This fever is common worldwide and it is responsible for damaging many heart valves. It is very uncommon in the United States. The occurrence is usually found in the isolated outbreaks. The latest outbreak was found in 1980’s. Usually the children aged between 6 and 15 are affected by rheumatic fever. The occurrence of this fever is usually found 20 days after scarlet fever and strep throat.

Symptoms of rheumatic fever include fever, abdominal pain, heart problems, joint pain, arthritis mainly in elbows, knees, wrists and ankles, joint swellings, warmth or redness, nosebleeds, skin nodules, skin rashes, Sydenham chorea etc.  The heart problems may not have any specific symptoms. Sometimes it may result into chest pain and shortness of breath.  A person may experience skin eruption on the trunk as well as on the upper part of the legs and arms. The eruption may look snake-like or ring-shaped. Sydenham chorea leads to muscle weakness, emotional instability, uncoordinated jerky movements that affect the feet, face and hands.

Different forms are found in this disease. Hence, a single test cannot firmly diagnose this disease. A careful exam maybe performed by the doctor who includes checking the heart, joints and skin.

The test may include:

  • Blood test if strep infection is recurrent. ASO test is a common test.
  • Electrocardiogram
  • Complete blood count
  • Sedimentation rate

Several minor and major criteria have been developed for standardizing the rheumatic fever diagnosis. If these criteria are met along with the evidence of streptococcal infection, the case of rheumatic fever can be confirmed.

The major criteria for diagnosing the fever include:

  • Joint pain or arthritis in joints
  • Heart inflammation
  • Jerky and rapid movements
  • Nodules under the skin
  • Rashes on skin

The minor criteria for diagnosing fever include:

  • High ESR
  • Fever
  • Joint Pain

The treatments for rheumatic fever vary. Antibiotics are used for treating acute rheumatic fever. Anti-inflammatory medications such as corticosteroids or aspirin can help in reducing the inflammation as well as managing acute rheumatic fever. One can also take low doses of antibiotics such as sulfa diazine, erithromycine and penicillin.

How it is determined that patients have a particular type of depression? The classification of depression is done on the basis of DSM guidelines issued by American Psychiatric Association.

DSM is an abbreviated form of Diagnostic and Statistical Manual of Mental Disorders. It is used by psychiatrists for diagnosing the mental conditions. The DSM guidelines are also used by insurance companies for providing reimbursement for treatment.

Diagnostic criteria for Major Depression

For major depression, a patient should satisfy following two conditions.

  • Patient must meet five or more of the following symptoms for more than two weeks period
  • Symptom must be either depressed mood or a lack of interest

Symptoms for Major Depression

  • Depressed mood during entire length of day almost daily
  • Feeling of sadness, or tearful in children and adolescents
  • Depressed mood appear as a sign of constant irritability
  • Diminished interest in doing all activities throughout the day almost daily
  • Considerable weight loss when not dieting or even weight gain
  • Increase/Decrease in appetite daily
  • Sleep disturbances like Insomnia/increased sleeping hours daily
  • Restlessness or slowed behaviour
  • Lack of energy or fatigue almost daily
  • Feelings of worthlessness/excessive guilt almost daily
  • Difficulty in making decisions
  • Difficulty in concentrating
  • Suicidal thoughts almost daily

Moreover, there are certain features that are peculiar to major depressions.

  • Symptoms do not highlight mixed episode such as simultaneous mania and depression as in bipolar disorder.
  • Severity of symptoms interferes with normal activities at school, work, or social activities.
  • Symptoms do not result due to direct consequences of taking medication, drug abuse or any associated medical condition like hypothyroidism.
  • Symptoms do not result due to any temporary life event such as sadness after the death of a loved one.

Diagnostic Criteria of Bipolar Disorder

There are basically two subtypes of bipolar disorder including Bipolar I disorder and Bipolar II disorder.

Bipolar I disorder: Minimum one manic episode + with or without major depressive episodes

Bipolar II disorder: Minimum one episode of major depression + at least one hypomanic episode

Diagnostic Criteria of Dysthymia

The diagnostic criteria of Dysthymia involve the following.

  • Symptoms must have lasted for a longer period of time (two years of more)
  • Symptoms must be less severe than symptoms of major depression
  • Symptoms should not result due to substance abuse or any medical condition
  • Symptoms should cause clinically significant distress
  • Symptoms should cause impairment in social and occupational areas of your life

Diagnostic Criteria of Postpartum depression

It is a common type of depression that starts four to eight weeks after delivery and may continue for months.

  • Depressed mood during entire length of day almost daily
  • Feeling of sadness, or tearful in children and adolescents
  • Depressed mood appear as a sign of constant irritability
  • Diminished interest in doing all activities throughout the day almost daily
  • Considerable weight loss when not dieting or even weight gain
  • Increase/Decrease in appetite daily
  • Sleep disturbances like Insomnia/increased sleeping hours daily
  • Restlessness or slowed behaviour
  • Lack of energy or fatigue almost daily
  • Suicidal thoughts

Melancholic Depression is basically a sub type of Clinical Depression. It is regarded as a severe form of depression that is more common in women than men.

It is characterised by lack of interest of individual in activities that were once pleasurable. Also, individuals become slower in response to the temporary positive life events.

Causes of Melancholic Depression

Melancholia Depression is supposed to be caused due to biological factors. It is believed to be genetically inherited in the offspring from their parents.

Common Risk Factors

  • Stressful situations excluding life changing events
  • Individuals who suffer from bipolar depression I
  • Individuals who suffer from bipolar depression II
  • Individuals with psychotic features
  • Elderly patients who have dementia

Symptoms of Melancholic Depression

  • Anhedonia
  • Severe weight loss,
  • Psychomotor agitation
  • Psychomotor retardation
  • Insomnia with early morning awakenings
  • Feeling of guilt or worthlessness
  • Diurnal variation with worse symptoms in the morning hours

Treatment of melancholic Depression

  • Antidepressants
  • Electroconvulsive therapy
  • Supportive psychotherapy
  • Deeper psychotherapy

Catatonic Depression

Catatonic Depression is basically a sub type of Clinical Depression. It is characterised by state of neurogenic motor immobility and behavioural abnormality expressed in form of Stupor.

Diagnostic criteria for Catatonic Depression

As per DSM-IV guidelines, a patient with catatonic depression must have at least two of the following signs.

  • Motor immobility including waxy flexibility or stupor (as evidenced by catalepsy)
  • Excessive motor activity
  • Extreme negativism (motiveless resistance to all instructions)
  • Maintenance of a rigid posture
  • Consistent posturing, stereotyped movements
  • Prominent mannerisms or grimacing
  • Echolalia

Symptoms of Catatonic Depression

  • Excessive Movement (Purposeless)
  • High resistance to suggestions
  • Loss of voluntary movement
  • Inability to react to one’s environment
  • Inappropriate voluntary movements
  • Involuntarily repeating some words meaninglessly
  • Extreme loss of motor skills or hyperactive motor activity
  • Holding rigid poses for hours
  • Stereotyped and repetitive movements
  • Waxy flexibility
  • Meaningless phrases

If not treated, patients with catatonic excitement may get exhausted. The catatonic depression may manifest itself in form of following syndromes.

  • Kahlbaum syndrome (retarded catatonia)
  • Malignant catatonia (neuroleptic malignant syndrome)
  • Excited forms (delirious mania)
  • Autism spectrum disorders

Treatment of Catatonic Depression

The treatment of Catatonic depression is done by experienced psychiatrist after careful and thorough evaluation.

Psychiatrist may recommend various anti-depressants and other therapies like ECT for treating the catatonic state.

Antidepressants used

  • Benzodiazepines are commonly prescribed in higher doses during initial stages of treatment.
  • Intramuscular lorazepam (1-2 mg) produces marked improvement in half an hour
  • Zolpidem is also used in diagnosis

Other Therapies

  • Electroconvulsive therapy (ECT) is very effective treatment for catatonic depression that targets the underlying causes.
  • Antipsychotics are also used however they require extreme caution as they can lead to worsening of symptoms and cause serious adverse effects
  • NMDA antagonists such as amantadine or memantine are effective against benzodiazepine resistant catatonia
  • Topiramate is also used for treating resistant catatonia.

Agitated Depression

It’s quite common to associate depression with state of low energy and slow physical or mental activity. Well, it is not always the case and Depression may manifest itself in form of physical and emotional agitation.

Agitated state of depression is basically a type of major depressive disorder that is characterized by physical and emotional restlessness, insomnia, and irritable mood.

The patients with agitated depression are driven by hypomania. They experience episodes of anger, agitation and irritability. Another name for agitated depression is mixed mania. Agitation is specifically severe in agitated depression patients.

Diagnostic Criteria for Agitated Depression

A psychiatrist does the diagnosis of agitated depression after carefully evaluating the symptoms of the patient. In some cases, agitation may also result from other severe cases of depression.

According to the Diagnostic criteria of Statistical Manual of Mental Disorders (DSM-IV), a patient is said to have agitated depression in case he/she meets both the following criteria.

  • Major depressive episode
  • Any two of the following manic episodes
  • Motor agitation
  • Psychic agitation
  • Racing thoughts

Forms of Agitated Depression

The agitated depression comprises of following three major forms.

  • Psychotic Agitated Depression (Severe form of melancholia)
  • Non-psychotic Agitated Depression (moderate form of agitation)
  • Excited Agitated Depression (Patient feels racing thoughts)

Treatment of Agitated Depression

The psychiatrists usually recommend the combination therapy including Psychotherapy and Medicines for treating agitated depression.

  • Psychotherapy involves imparting anger management skills and relaxing techniques to the patients.
  • Medication comprises of following medicines.
  • Mood stabilizers such as valproic acid and lamotrigine
  • Atypical antipsychotics such as olanzapine, ziprasidone and aripirizole

Psychotic depression

Hallucinations and delusions may be experienced by depressed patient in severe cases. Such form of depression is called as Psychotic depression that is characterised by severe depressive illness with co-existing psychosis.

Psychotic depression may be seen in patients hospitalised for depression. The psychosis may manifest in form of hallucinations, delusions, or unrealistic experiences. It is more common in patients suffering from schizophrenia.

Patients may see or hear imaginary sounds, voices and visuals. Unlike the manic depressive episodes, the hallucinations in psychotic depression are not “positive” and patient complains of frightening sounds and images.

Symptoms of Psychotic Depression

Patients with psychotic depression may present following symptoms.

  • Intellectual impairment
  • Physical immobility
  • Agitation
  • Insomnia
  • Anxiety
  • Psychosis
  • Constipation
  • Hypochondria

Treatment of Psychotic Depression

The treatment for psychotic depression is done by experienced psychiatrists in the hospital.

Medications used for treating psychotic depression include combinations of antidepressants and antipsychotic medications.

Common Antipsychotic/ Neuroleptic drugs are quetiapine, ziprasidone, risperidone, and olanzapine.

These affect neurotransmitters and are better tolerated than earlier antipsychotics drugs.

The antipsychotic medications are usually effective and patients are usually recovered within a year. In some cases, psychiatrists may recommend electroconvulsive therapy (ECT) for those patients who do not respond to medications.

As the psychotic depression is a serious disease, it is imperative for the patients to work closely with the doctors so that doctors can prescribe most effective drugs with minimum side effects.