Understanding Depression

Madan BaralSecond Semester, B.

Pharmacy

School of Health and Allied Sciences

Pokhara University, Dhungepatan, Lekhnath-12,

Kaski , Nepal

Objectives• Understand Signs and Symptoms• Differentiate between types of depression• Understand Causation• Understand Diagnosis Methods• Understand Treatment

WHAT IS DEPRESSION ?• common potentially

debilitating psychiatric disorder characterized by depressed mood, loss of interest or pleasure, feelings of guilt, disturbed sleep or appetite, low and poor concentration.

HISTORY• Ancient Egyptians wrote about depression more

than 3000 years ago• Ancient Greek thought depression as the cause of

excess of bile• Hippocrates, first person to throughly describe the

condition as a somatic illness and coin the term “melancholia”

• Ludwig Van Beethoven, Charles Dickens, Winston Churchill, Abraham Lincoln and Ernest Hemingway some famous people said to have suffered from depression

CLASSIFICATION ON THE BASIS DSM-IV • Depression classified with its subtypes under Mood Disorder by

American Psychiatric Association published in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)

✦ Mood DisorderA. Depressive Disorder

1.Major Depressive Disorder, Single Episode2. Major Depressive Disorder, Recurrent3. Dysthymia Disorder4. Depressive Disorder Not Otherwise Mentioned

– Bipolar Disorder» Bipolar Disorder, Single Episode» Bipolar Disorder, RecurrentA.Cyclothymic Disorder1.Bipolar Disorder Not Otherwise Specified

1. Secondary Mood Disorder due to Non-psychiatric Medical Condition

2. Substance- Induced Mood Disorder3.Mood Disorder Not Otherwise Specified

Facts and Statistics• People of all ages, backgrounds, lifestyles, and

nationalities suffer from major depression, with a few exceptions.

• Up to 20% of people experience symptoms of depression.

• The average age of first onset of major depression is 25-29

• Ranked as 4th highest public concern according to WHO and assumed to be 2nd by 2020

Major Depressive Disorder• Also called clinical depression or unipolar

depression• The most prevalent depressive disorder • Some 340 million persons worldwide meet the

criteria for clinical depression

Symptoms•The symptoms of depression are:

Emotional Symptoms: Physical Symptoms:Depressed mood Change in body weight and

appetite

Loss of interest or pleasure

Disturbances of sleep and other Circadian rhythm

Anxiety Fatigue

Diminished ability to think or concentrate, or indecisiveness

Psychomotor agitation or retardation

Feeling of excessive or inappropriate guilt

Unexplained body aches

Recurrent thoughts of deaths and suicidal

Headache

Types • Classified further on the basis of occurrence

a. Single Episodeb. Recurrent

• Single episode - occurs only once and meets all the diagnostic symptoms of major depression

• If untreated, 85% of persons who have one episode of depression will have another episode within 10 years

• Recurrent-2 major depression episodes, separated by at least a 2 month period

• Median number of depressive episodes per person is 4

• 25% have 6 or more episodes

Dysthymia• chronic “low-grade” or mild depression• symptoms not as strong as the symptoms of major

depression• Diagnostic Symptoms :

A. Depressed/irritable mood

B. Presence of two of the following:

• Appetite disturbance

• Sleep disturbance

• Low energy/fatigue

• Poor concentration of difficulties making decision

• Feelings of hopelessnessC. Present for two year period (one year in children and adolescents)

Bipolar Disorder• manic-depressive disorder• presence of one or more episodes of abnormally

elevated energy levels, cognition, and mood with or without one or more depressive episodes

Characteristic Episodes– Depressive Episode :disturbances in sleep and appetite, fatigue,

–Manic Episode : elevated, irritable mood state ,grandiosity

–Hypomanic Episode : milder mania

Etiology and PathophysiologyA.Biological Theories

1.Genetics2.Biochemical Theories

a. Monoamine Hypothesisb. Neurotransmitter Dysregulation Hypothesisc. Neuroendocrine Findings

B.Psychological Theories1. Psychoanalytical FactorsA. Learning Theories1. Object Loss theory2. Cognitive Theory

a. Social Theorya.Family Basedc.Society Based

GeneticsFamily Studies• first degree relatives of (children,siblings,parents) of depressed individuals are 1.5 to 3 times more likely to have depression compared to general population

Twin Studies •concordance rate of monozygotic twins ranges from 54-65% while in dizygotic twins in only 15-24

Biochemical Theories

• Monoamine Hypothesis• Neurotransmitter Dysregulation Hypothesis

• Neuroendocrine Findings

Monoamine Hypothesis• Depletion in the levels of serotonin, norepinephrine,

and/or dopamine in the CNS.

• Norepinephrine regarded as the component in the mobilization of the body toy deal with stressful event.

• Serotonin System- mood and arousal thinking,energy, libido, cognition,appetite,aggression and circadian rhythm.

• Dopamine System -human mood and behavior.

• Decreased level of biogenic amines in synaptic cleft inhibits the transmission of impulses from one neuron to another causing a failure of the cells to fire or charge.

• Pathophysiology supported by the mechanism of action of antidepressants and autopsy of depressed person

Monoamine HypothesisLimitations• Delayed onset of drug• Not all the depressed patient have decreased synaptic concentration of of biogenic amines• antidepressant can work via other mechanisms which do not involve reactive increased in synaptic neuro-transmitter concentration (eg. can block corticotropin releasing factor)

Neurotransmitter Dysregulation Hypothesis• Explains depression as the cause of failure of

regulation of neurotransmission system

Factors - Impairment in homeostasis or regulation- Disruption of normal periodicity ( Circadian rhythm )

- less selective response to stimuli

Neuroendocrine Findings• Neuroendocrine abnormalities may develop

depression• Abnormal thyroid function test including low

triiodothronine(T3) and thyroxine(T4)• Abnormal response to TRH(thyroid releasing

hormone) consisting or blunted or exaggerated thyroid stimulating hormone (TSH)

• Clinical hypoparathyroidism • HPA axis influence manifestation of depression• Concentrations of CRF is elevated during

depressive episodes• Decreased hippocampus

Psychological Theories

• Psychoanalytical Theory• Learning Theories• Object Loss theory• Cognitive Theory

Psychoanalytical Theory• Sigmund Freud features of melancholia

– a profoundly painful dejection– loss of interest in world – loss of capacity to love

• Interpretation of melancholia– actual loss of loved one or emotional rejection – feelings of self-hatred develop and worthlessness and losses his or her self-esteem

Learning Theory• Seligman’s “learned helplessness” experiment on

dogs• Helplessness in human with numerous traumatic

situations either real or perceived• Seligman’s interpretation of depression

–Learned helplessness predisposes depression by imposing a feeling of lack of control and hopelessness over their life situation and failures

Object Loss Theory (Attachment Theory)• Attachment theory by John Bowlby, English

psychiatrist,• Relationship between depressive disorder in

adulthood and the quality of the earlier bond between the infant and their adult caregiver.

• The experiences of early loss, separation and rejection by the parent or caregiver

• Absence of security and emotional absence

Cognitive Theory• Put-forth by Aaron Beck• 3 cognitive distortion reality• Negative expectation

– Environment– Self– Future

• Contrary view

Social Theory• Family

–Problems with family–Family stress

• Social–Substantial life events–Social isolation

Diagnosis

•Clinical Assessment •Behavioral Rating Scales•DSM-IV Criteria and IDS-10 Criteria

Clinical Assessment• By Clinician,trained medical practitioner,

psychiatrist or psychologist• Mental state assessment – appearance, behavior speech, mood, memory,

and intellectual function• Physical Examination– palpitation in neck, laboratory tests ( TSH,

thyroxine, testosterone level)• Other bodily changes

Behavioral Rating Scales• Set of questionnaire for depression assessment •Uses

– Screening mental state – Quantifying target symptoms– Determine treatment efficacy

•Clinically preferred– Hamilton Rating Scales for Depression (HRS-D)– Montgomery-Asberg Rating Depression Rating Scale

–National Institute of Mental Health Diagnostic Interview Schedule (DIS)

DSM-IV Criteria and ICD-10 Criteria• DSM-IV

– American Psychiatric Association's revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)

• ICD-10– World Health Organization's

International Statistical Classification of Diseases and Related Health Problems (ICD-10)

Treatment• Non-Drug Therapy

–Psychotherapy–Phototherapy–Electroconvulsive Therapy

• Pharmacotherapy

Psychotherapy• Interpersonal therapy:

–assist in solving relationship problems that cause depression

• Cognitive-behavioral therapy:– changes the pessimistic ideas and unrealistic expectations

–develop positive life goals, and a more positive self-assessment

Electroconvulsive TherapyHow is it done?•Pulses of electricity are sent through the brain via two electrodes•Painless procedure•A person is put to sleep with general anesthesia•Muscle relaxers are used to prevent any injury from the procedureAdvantages•Quicker effect than antidepressant therapy and thus may be the treatment of choice in several emergency occasions

Pharmacotherapy• Use of antidepressants • Selective serotonin-reuptake

inhibitors (SSRIs) like fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram

• Tricyclic Antidepressants(TCAs) like amitriptyline,

• Monoamine oxidase inhibitors (MAOIs)

References• Young Kimble (2000) et al., Applied Therapeutics: The Clinical Use

of Drugs (7th Ed.), Lipincott Williams & Wilkins, Baltimore, pp 77-77-21.

• Kasper et al., Harrison’s Principle of Internal Medicine (16th Ed.), McGraw and Hill Companies, New Delhi, pp 2553-2557.

• Boyd Nihart (1998) Psychiatric Nursing Contemporary Practice, Lipincott Williams and Wilkins, New York, pp 438-472.

• Basavantha BT (2007) Psychiatric Mental Health Nursing (1st Ed.) Jaypee Brothers Medical Publishers Ltd New Delhi, pp 494-521.

• URL-1: http://www.who.int/mental_health/management/depression/definition/en/ (Accessed on October 1, 2010)

• URL-2: http://en.wikipedia.org/wiki/Major_depressive_disorder#Symptoms_and_signs

• URL-3: http://www.helpguide.org/mental/depression_signs_types_diagnosis_treatment.htm

THANK YOU