DEPRESSION

DEPRESSION: DEFINITION

• Persistent low mood,

• Lack of positive affect,
Depression is • Loss of interest in usually pleasurable
activities
a condition • Neuro-vegetative symptoms:
characterized • changes in sleep, energy level,
by psychomotor activity, appetite,
concentration.
• Impairs persons’ daily functioning.
 SUBTYPES OF DEPRESSION

psychotic • delusions or hallucinations, either may be congruent or

depression incongruent with depressed mood

• Has at least 2 of

catatonic • immobility (stupor or catalepsy)

• extreme agitation
• extreme negativism

depression • odd voluntary movement (posturing, stereotyped movements,

mannerism, grimacing)
• echolalia or echopraxia
 • lack of interest or pleasure in most or all activities, or
lack of reactivity to pleasurable stimuli, and ≥ 3 of

melancholic • distinct quality of depressed mood (experienced

differently from loss of a loved one)

depression • symptoms regularly worse in morning

• early morning awakening (at least 2 hours before

– usual time of awakening)

• significant anorexia or weight loss
• noticeable psychomotor retardation or agitation
• excessive or inappropriate guilt
 • mood reactivity and ≥ 2 of
atypical • leaden paralysis
• lengthy pattern of interpersonal rejection sensitivity
depression – • significant weight gain or appetite increase
• Hypersomnia

seasonal
pattern • regular temporal relationship between time of year and
symptom onset/remission
depression –

Post partum depression

 • Several depressive-spectrum disorders
(DSM-IV). are included the American Psychiatric
Association's Diagnostic and Statistical
Manual of Mental Disorders

• Dysthymia is a syndrome of milder

Dysthymia symptoms, but other patients have
major depressive symptoms and can
be suicidal.
 Unipolar Bipolar
Depressive Disorder.
Disorder
When the pattern of
recurrence is one of When manic-like
depressive syndromes episodes are included
only, the disorder is the disorder is called a
called a unipolar bipolar disorder.
depressive disorder.
 DEPRESSION
Depression is the
Depression is a leading
common mental cause of
disorder. disability More women
Globally, more worldwide, and are affected by At its worst,
is a major
than 300 million contributor to depression than depression can
people of all men. lead to suicide.
the overall
ages suffer from global burden
depression. of disease.
 DEPRESSION IN CHILDREN AND ADOLESCENTS
overall prevalence of depression 2.8% in patients < 13
years old and 5.6% in patients aged 13-18 years

18% prevalence among young adolescents

15% lifetime prevalence of major depression in United

States adolescents and young adults
20% of adolescents admitted to emergency department
met criteria for moderate-to-severe depression
In India depression is the commonest psychiatric illness in
the geriatric age group . Its prevalence is about 6.7% of
elderly population.

depression in late life have serious consequences,

including disability, functional decline, diminished quality of
life, mortality, from co morbid medical conditions or suicide.

Because of the seriousness of these consequences, geriatric

depression has been identified as a major public health
problem, yet it is undiagnosed in 50% of cases.
 Depression is the commonest psychiatric illness in the elderly and
various factors unique to old age play a role in the occurrence of
depression.

Old age has been • inevitable decline in physical vigor,

described as a ‘season • mental agility,
of loss’ and depressive
reactions as response • income,
to losses, including • loss of loved ones.
 Depression in this age group has been
associated with a number of adverse
outcomes including

functional impairment increased health services

,
medical illnesses , disability , utilization .
 THE BURDEN OF DEPRESSION

Depression is an
independent factor • All cause mortality
• Acute stroke
impacting a range • Diabetes
of medical • Myocardial infarction
conditions and • Cardiovascular disease
increasing risk of • Congestive heart failure
death and • HIV
hospitalization:
 MEAN HEALTH SCORE IN DEPRESSED PEOPLE

Amongst people with one chronic condition, depressed respondents

had lowest mean health score (published in Lancet, in 2007).

Conditions compared • Asthma, Angina, Arthritis, Diabetes,

were: Depression.

Depressed respondents with another chronic condition had lower mean

health scores than respondents with the chronic condition alone.
 THE IMPACT OF DEPRESSION
Of the 30,000 people in the U.S. who commit suicide each year, 60 percent have depression

Increased risk of substance abuse/dependence

Increased medical co-morbidities

Strain on interpersonal relationships

Estimated U.S. economic burden: $83.1 billion in 2000

World Health Organization reported that MDD is projected to become the second leading cause of
disability worldwide by 2020
 PATHOGENESIS:
Altered • decreased serotonin, decreased dopamine, and decreased
neurotransmitter levels : norepinephrine

• abnormal stress hormones, decreased thyroid-stimulating hormone (TSH),

growth hormone, follicle-stimulating hormone, luteinizing hormone,
Biochemical changes: testosterone, immune function; decreased TSH response to thyrotropin-
releasing hormone, decreased prolactin response to tryptophan

Depression is • lower occipital cortex GABA levels and higher glutamate levels
associated with
 DEPRESSION AND GENETICS

• A SINGLE GENE HAS BEEN SHOWN TO HAVE HIGH CORRELATION WITH DEPRESSION
• CODES FOR SEROTONIN TRANSPORTER
 DEPRESSION AND GENETICS

Getting the short end of the gene:

Why stressful experiences lead to depression in some people but not in others?

A functional polymorphism in the promoter region of the serotonin transporter (5-HT T) gene was found to moderate the
influence of stressful life events on depression.

Individuals with one or two copies of the short allele of the 5-HT T promoter polymorphism (SS or SL) exhibited more
depressive sxs, diagnosable depression, and suicidality in relation to stressful life events than individuals homozygous for the
long allele (LL).
ETIOLOGY OF DEPRESSIVE DISORDERS IN OLDER
PERSONS

Risk factors

Physical illness • chronic ill health contributes to a poor prognosis in depressive

disorders, and the presence of a depressive disorder can also
and disablement – worsen the outcome of physical illness.

Personality factor • certain personality traits e.g. dependent, avoidant,

“anxiety-prone” – might be related to depression in
– old age
ETIOLOGY OF DEPRESSIVE DISORDERS IN
OLDER PERSONS

Significant • bereavement, separation, acute physical illness, medical illness or

threat to the life of a beloved person, sudden homelessness or loss

life event – of residence, major financial crisis, negative revelation regarding a

family member or friend, loss of valuable or meaningful object(s)

Chronic • declining health and mobility, dependence, sensory loss, cognitive

source of
decline, housing problems, major problems affecting a family
member, marital difficulties, socioeconomic decline, problems at
work/ retirement, caring for a chronically ill and dependent family

stress – member
 AGEING AND DEPRESSION
Numerous studies suggest that structural, vascular, neuroendocrine,
and biochemical changes in the brain significantly influence late-
life depression.
Brain structure changes • cerebral atrophy, subcortical hyperintensities and gray-
(structural imaging matter disease involving the basal ganglia, caudate, and
studies): thalamus, white-matter hyperintensities etc.

Brain metabolic • abnormal metabolism of caudate nucleus, basal ganglia

changes (functional and the frontal region, reduced activation of the dorsal
imaging studies): anterior cingulate.
 • high levels of Corticotropin-releasing
hormone- messenger ribonucleic acid (CRH-
Neuroendocrine mRNA) in the paraventricular nucleus;
changes: association of interleukin-6 (an interleukin in
cortisol production, inflammation and immune
system) with depressive disorder in later life

• age-related reductions in dopaminergic

Neurochemical function may predispose individuals to
depressive disorders, reduction in CSF HVA
changes: levels is accompanied by increased brain,
plasma, and CSF MAO-B activity
Depressed Mood
Reduced Interest Or Pleasure In Activities Previously Enjoyed, Loss Of Sexual Desire
Unintentional Weight Loss (Without Dieting) Or Low Appetite
Insomnia (Difficulty Sleeping) Or Hypersomnia (Excessive Sleeping)
Psychomotor Agitation, For Example, Restlessness, Pacing Up And Down
Delayed Psychomotor Skills, For Example, Slowed Movement And Speech
Fatigue Or Loss Of Energy
Feelings Of Worthlessness Or Guilt
Impaired Ability To Think, Concentrate, Or Make Decisions
Recurrent Thoughts Of Death Or Suicide, Or Attempt At Suicide
 DIAGNOSTIC CRITERIA OF DEPRESSIVE
EPISODE
Depressed mood to a degree that is definitely abnormal for the individual, present for most of the day and almost
every day, largely uninfluenced by circumstances, and sustained for at lease 2 weeks

Loss of interest or pleasure in activities that are normally pleasurable

Decreased energy or increased fatigability

An additional symptom or symptoms from the following (at least four):

Loss of confidence or self esteem

 Diagnostic criteria of depressive episode
Unreasonable feelings of self-reproach or excessive and inappropriate guilt

Recurrent thoughts of death or suicide, or any suicidal behaviour

Complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or

vacillation

Change in psychomotor activity, with agitation or retardation (either subjective or objective)

Sleep disturbance of any type

Change in appetite (decrease or increase) with corresponding weight change

WHO. ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva, Switzerland: World
Health Organization
 RUBRICS
• MIND - SUICIDAL disposition - sadness, from
• alum. AUR. AUR-M. Aur-m-n. Aur-s. calc. caust. chin. cimic. con. graph. Hep. hydrog. ign. med. Merc-aur. morph. naja Nat-m.
Nat-s. nat-sil. op. Psor. ran-b. rumx. sep. Spig. STAPH. sulph.

• MIND - DELIRIUM – sad acon. bell. puls.

•
• MIND - DESPAIR
• . AMBR.. AUR.. CALC. COFF. colch. coli. COLOC.. HELL.. IGN. LYC.. NAT-M. PSOR. SULPH.. VERAT.

• MIND - SADNESS - despair; with Agn. HELL. Plat. Sars.

• MIND - LOATHING - life - old people; in calc.
• MIND - INACTIVITY
• . Bar-c.. Chel.. Luna Mag-m. nat-sil.. Zinc.
• MIND - GRIEF - silent
• Am-m. ANTHRACI.. IGNMur-ac. NAT-M.. Ph-ac. phos. Puls. h. Symph.
 MANAGEMENT AND PREVENTION

Comprehensive assessment of the patient’s physical, social, and psychological state

(and past history) is essential.

• Mobility & Activity

• Sensory impairments
• Nutritional state
Important factors to •
•
Specific physical disorders and their current treatment
Past history of depressive or other psychiatric disorders and their treatment
be assessed: • Family and informal caregiver support network
• Statutory care input
• Unmet needs
• Recent losses
 CURRENT DEPRESSION TREATMENT OPTIONS

Pharmacologic • Antidepressants and augmentation treatments

• Psychotherapy
• Cognitive behavioral therapy
• Interpersonal therapy

Non- • Psychodynamic therapy

• Life style changes and mindfulness
• Phototherapy
pharmacologic •
•
Electroconvulsive therapy
Deep Brain Stimulation (DBS)
• Vagus nerve stimulation
• Repetitive Transcranial Magnetic Stimulation (rTMS)
 PSYCHOTHERAPY

Cognitive • CBT offers a practical approach, focusing on managing symptoms

rather than on origins of symptom-causing conflicts:
Behavioral • Patients gain insight to their cognitive distortions and learn to
control automated negative thoughts, learn relaxation and
Therapy breathing techniques.

Supportive • focuses on emotional support and finding practical solutions to

everyday problems.
therapy
 PSYCHOTHERAPY

Interpersonal therapy focuses on the here-and-now of interpersonal problems which are

worked through the relationship with the psychotherapist and may involve understanding
of past transference reactions.

Psychodynamic therapy has its origin in Psychoanalysis and focuses mainly on the origins of
conflict, childhood events and psychic determinism stemming from those early events and
attachment patterns. The resolution of symptoms occurs when the conflict is brought to light and
worked through in therapy.
 LIFE STYLE CHANGES AND MIND-BODY
INTERVENTIONS:

Yoga classes for 5 weeks may reduce depression and anxiety

Mindfulness-based cognitive therapy may delay relapse for

patients with recurrent depression

Music therapy may be effective for improving mood in depression

Spirituality education program (8-week audio-taped program)

associated with reductions in depression, tension, anger and fatigue
 PHOTOTHERAPY

Light therapy is used in Seasonal Affective Disorder (winter depression) and non-Seasonal
Affective Disorders.

It is generally safe in treating depressed persons, pregnant women and also elderly

Daily treatments of 30 min and above

 CLINICAL ASSESSMENT

KEY QUESTION TO ASK THE PATIENT

How is your mood?
Have you lost interest in anything?
Do you get less pleasure from things you usually enjoy?
How long have you had symptoms?
Have you been diagnosed before with a depressive disorder?
Have there been any important health changes within the past year?
Have there been any major changes in your life in the preceding 3 months?
Have there been any symptoms to suggest underlying physical illness (for example, weight loss)?
Have you ever thought you would be better off dead?
QUESTIONS TO ASK SOMEONE WHO KNOWS THE PATIENT WELL
What changes have you noticed in the person?
What is his/her personality normally like?
Is there a history of depressive disorder in a blood relative?