Depression, Global and Indian Scenario, Cognitive Behavior Therapy, Aetiology of depression,Treatment, Diathesis Stress Theory, Genetic theories, Biochemical Theory, Suicide, DSM-V, cognitive distortions.

1. DEPRESSION
One of the most common Mental Health
Disorders in the world.

2. Global and Indian Scenario
Globally, more than 264 million people of all
ages suffer from depression.
a major contributor to the overall global
burden of disease.
Although there are known, effective treatments
for mental disorders, between 76% and 85% of
people in low- and middle-income countries
receive no treatment for their disorder
Prevalence of depression is 1.2% to 21% in the
clinic-based studies; 3%–68% in school-based
studies and 0.1%–6.94% in community studies, in
India.
The age onset of depression is decreasing and
has increasingly been found in children and
Adolescence.
Symptom Profile: Most common symptoms
experienced are low mood/sadness, crying
spells, decreased interest in activities, problems
with concentration.

3. Clinical Features
• Sadness/low mood- maybe present throughout the day (persistant
sadness). Diurnal variation- sadness varies through the day- sad during
mornings or evenings only.
• Loss of pleasure in all activities (anhedonia- in severe cases)- resulting
social withdrawal, functional deficit- decreased functioning in
• Occupational and interpersonal areas.
Depressed
Mood
• three common types of ideas- Hopelessness of the future,
Helplessness (nobody nothing can help) and worthlessness (low self-
esteem, inferiority, inadequacy)
• Felling guilt, low concentration, slowed thinking, poor memory,
ruminations- repetitive, intrusive thoughts of pessimistic ideas
• Suicidal ideations- thoughts of committing suicide, preoccupation
with death etc.
Depressed
Cognition

4. Clinical Features
• Psychomotor Retardation- slowed thinking and activity, decreased
energy and monotonous voice. In severe cases depressive stupor- no
movement (catatonic) and lack of response to stimuli.
• Older patients agitation is common, anxiety, restlessness
• Anxiety is also common with anger, frustrations etc.
Psychomotor
Activity
• Insomnia (loss of sleep) or sometimes increased sleep
• Decreased appetite or sometimes increased appetite
• Fatigued easily, body aches, heavy head
• Loss of libido
• Hypochondriacal features- health anxiety
• Person may consult a physician before a psychologist or a psychiatrist
Physical
Symptoms

5. Clinical Features
• In severe cases about 15-20% have psychotic features like
hallucinations, delusions, stupor, inappropriate behavior.
• nihilistic delusions, delusions of guilt etc.- mood congruent-
congruent with depressed mood.
•
Psychosis
• Risk of suicide though always present, some factors increase the risk.
• Being impulsive, previous unsuccessful suicidal attempt
• Hopelessness in the future
• Has a detailed suicidal plan and a strong suicidal intent
• Lack of perceived social support
• Living Alone
Suicide

6. Major Depressive Disorder- DSM-V
1
2
3
Five or more of the following present in a two week period
Depressed mood most of the day, nearly every day- feels sad, empty, hopeless,
appears tearful. In children and adolescence- irritability can be considered.
Markedly diminished interest or pleasure in all, or almost all, activities most of the
day, nearly every day. Anedonia
Significant weight loss or weight gain or decrease or increase in appetite nearly
every day. In children, consider failure to make expected weight gain.
4 Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every day (observable by
others, not merely subjective feelings of restlessness or being slowed down).
Fatigue or loss of energy nearly every day.
5
6

7. Major Depressive Disorder- DSM-V
7
8
9
Five or more of the following present in a two week period
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan for committing
suicide.
BThe symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
The episode is not attributable to the physiological effects of a substance or
to another medical conditionC
Feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day
Diminished ability to think or concentrate, or indecisiveness, nearly every
day (either by subjective account or as observed by others).

8. Risk and Prognostic Factors
1
2
Risk Factors: Neuroticism (negative affectivity) is a
well-established risk factor
Stressful life events are recognized as precipitants of
major depressive episodes
First-degree family members with major depressive
disorder have a higher risk for major depressive
disorder
Good Prognostic Factors: Acute or abrupt onset. Typical
clinical features
Well-adjusted premorbid personality
Good response to treatment
Bad Prognostic factors: Co-morbidity medical disorder,
personality disorder or alcohol dependence
Catastrophic stress or chronic ongoing stress
Unfavorable early environment

9. Persistent Depressive Disorder (PDD)- DSM-V
A. Depressed mood for most of the day, as subjectively observed account or observation by others, for at least 2
years. In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. While depressed two (or more) of the following present:
1. Increased or Decreased Appetite
2. Loss of Sleep (insomnia) or Excessive Sleep (hypersomnia)
3. Fatigue.
4. Low self-esteem, worthlessness
5. Poor concentration or difficulty making decisions.
6. Hopelessness.
C. During the 2-year period the individual has never been without the symptoms in Criteria A and B for more than 2
months at a time
D. Criteria for Major Depressive Disorder maybe met for continuously 2 years
E. The symptoms cause significant distress and functional deficit in social, occupational etc.
E. There has never been a manic episode or a hypomanic episode, and cyclothymic disorder.
F. The disturbance is not better explained by any other disorder
G. Symptoms not explained by the effects of any substance, medical disorder etc.
Risk Factors: Childhood parental loss and separation, higher levels of neuroticism, genetic first degree
relatives with PDD.

10. Aetiology (causes) of Depression
• Heritability rate for
depression is 37%.
Heritability is also seen in
severe types of
depression.
• Family studies- 2-3 fold
increase in the risk of
depression in first
offspring of patients with
depression.
• The severity of illness
depends on whether they
are inherited from
mother or father.
Biological Theories-
Genetic Hypothesis1 2
• Insufficiency of monoamine
neuromediators (serotonin,
norepinephrine, dopamine) in
structures of the central nervous
system may lead to depression.
• depression as a
psychoneuroimmunological
disease in which the release of
anti-inflammatory cytokines can
cause the various behavioral,
neuroendocrine, and
neurochemical changes
observed in this disorder
Psychosocial Theories3
• Chronic stress and stressful life events early in
life are strong proximal predictors of the
initiation and onset of depression.
• The “stress-induced” theory onset
hypothesized that hyperactivity of the HPA-
(Hypothalamic–pituitary–adrenal axis- plays
key role in body’s response to stress) system
may be an important mechanism underlying
the development of depression after
exposure to stress.
• Diathesis stress Model- Individual’s
vulnerability or predisposition to depression
may be activated by environmental stressors,
resulting in developing depression.
Biochemical Theories

11. Cognitive Behavior Therapy and Depression
List of Cognitive
Distortions:
• Arbitrary Inference or
Catastrophizing
• Selective Abstraction
• Overgeneralization
• Dichotomous or Black
and White thinking
• Personalization
• Labelling or Mislabelling
• Fallacy of Fairness
• Fallacy of Control
Aron T Beck developed Cognitive Therapy
as a result of his research on depression.
He observed that negative biases in their
interpretation of certain life events resulted
in psychological problems (cognitive
Distortions)
He introduced the cognitive triad- consists
of three forms of negative core beliefs a
person with depression has about the
world- Negative core beliefs about the
world, self and future.
Automatic negative thoughts- personalized
notions triggered by particular stimuli
leading to emotional responses- are a result
of core beliefs and intermediate beliefs that
are formed as result of childhood
experiences.

12. Cognitive Behavior Therapy and Depression
Figure 1: Cognitive Therapy Model for Depression. By- Cognitive
Behavioral Therapy for Depression, Manaswi Gautam, Adarsh
Tripathi, Deepanjali Deshmukh, and Manisha Gaur, 2020.
Early life experiences resulting in negative core
beliefs or schemas formed about self, others, world
and future and intermediate beliefs- (if and then
rules, standards and assumptions that a person lives
by. Ex: If I always please others then I will be loved,
if I achieve, then I am not stupid and hence, I should
always achieve) which then lead to negative
automatic thoughts and negative core beliefs of the
cognitive traid, when triggered by an external
critical/stressful event resulting in a range of
behaviors, emotions and physical symptoms,
Ultimately leading to Depression.

13. Treatments for Depression
Medicines
• Antidepressants
• Selective serotonin reuptake inhibitors (SSRIs)
• Serotonin and norepinephrine reuptake inhibitors (SNRIs)
Psychotherapies
• Cognitive Behavior Therapy- Thought Record, Insight
oriented, Disputation, Re-framing, Worksheets,
Homework, Bibliotherapy etc.
• Behavioral Activation for Depression
• Interpersonal Therapy: Improving interpersonal
relationships by expressing emotions and solving
problems. Helps in gaining a sense of social support for
coping with depression and life events. Builds social
skills.

14. References
• DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FIFTH EDITION DSM-5
• A short Textbook of Psychiatry- Neeraj Ahuja 7th Edition- 2011
• Overcoming depression: How psychologists help with depressive disorders- American Psychological Association,
2016 https://www.apa.org/topics/overcoming-depression.
• Cognitive Behavioral Therapy for Depression, Manaswi Gautam, Adarsh Tripathi, Deepanjali Deshmukh, and Manisha
Gaur, 2020. Indian Journal of Psychiatry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7001356/
• Genetics Factors in Major Depression Disease, 2018, Maria Shadrina, Elena A. Bondarenko,* and Petr A. Slominsky.
Frontiers in Psychology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6065213/
• Depression in Children and Adolescents: A Review of Indian studies, 2019 Sandeep Grover, V Venkatesh
Raju, Akhilesh Sharma, and Ruchita Shah. Indian Journal of Psychological Medicine.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6532377/#:~:text=Available%20data%20suggest%20that%20the,the
%20incidence%20to%20be%201.6%25.
• Depression, 2020, World Health Organization. https://www.who.int/news-room/fact-sheets/detail/depression