This document discusses depression, including its definition as a layman term, symptom, syndrome, or disorder. It describes the core symptoms of depression and different types including melancholic depression. The continuum of depression is presented, distinguishing depression from normal sadness. Major depressive disorder and dysthymic disorder are explained according to DSM-IV criteria. Theories on the etiology and risk factors for depression are mentioned. A case scenario of postpartum depression with psychotic features is provided and analyzed in terms of diagnosis, etiology, problems, and treatment approach.
3. Mood Disorders
A disabling disturbance in
emotion
– Depression
Sadness
Feelings of worthlessness and guilt
Withdrawal from others
Reduced sleep, appetite, sexual desire
– Mania
Intense elation
Hyperactivity
Talkativeness
Distractibility
Depressed Mood
Depression
Mania
Elevated Mood
4. What Is Depression?
Depression has various meanings
It can be
– A layman term
– A symptom
– A syndrome
– A disorder
5. A Layman Term
A man was admitted to a medical ward for
an illness. The doctor and nurses noticed
that he was quiet and spent most of his time
on bed. They think he might be depressed...
6. A Symptom
A man was admitted to a medical ward for
an illness. The doctor and nurses noticed
that he was quiet and spent most of his time
on bed. When asked, he said that he feel
sad because the illness had affected his job.
However, his sleep and appetite were
normal.
7. A Syndrome
A man was admitted to a medical ward for
an illness. The doctor and nurses noticed
that he was quiet and spent most of his time
on bed. He was sad because the illness had
affected his job. He had disturbed sleep and
lost of appetite for the past 2 weeks.
8. A Disorder
A man was admitted to a medical ward for
an illness. The doctor and nurses noticed
that he was quiet and spent most of his time
on bed. He feel sad because the illness had
affected his work. He has disturbed sleep
and lost of appetite for the past 2 weeks.
Further history revealed that he had previous
similar episodes in the past and his mother
also suffered from similar illness.
9. Symptom, Syndrome and
Disorder
A layman term is often based on behavioral
observation only
A symptom is based on behavioral
description as well as phenomenology
A syndrome is a recognizable group of
symptoms (number, duration, impairment)
A disorder is a syndrome with the presumed
etiology
11. Three Approaches to
Psychopathology
Phenomenological psychopathology
– Objective description, and avoid theories or
assumptions
– Entirely concern with
Conscious experiences (as the patient experienced
them) and
Observable behaviors (as others saw them)
Psychodynamic psychopathology
Experimental psychopathology
12. Depressive Symptoms
Core symptoms
– Depressed mood
– Loss of interest or pleasure (anhedonia)
Psychological and cognitive symptoms
– Feelings of worthlessness
– Excessive/inappropriate guilt
– Diminished ability to think, concentrate or
indecisiveness
– Recurrent thought of death or suicidal
ideation/plan/attempt
13. Cont.
Biological, somatic, behavioral or
neurovegetative symptoms
– Weight loss/gain or increase/decrease appetite
– Insomnia or hypersomnia
– Psychomotor agitation/retardation
– Fatigue or loss of energy
14. Continuum of Depression
Threshold for MDE
MDE as part of Major Depressive Disorder
MDE as part of Bipolar Disorders
Depressive Disorder NOS
Dysthymic Disorder
Adjustment Disorder With Depressed Mood
Bereavement
Normal sadness
15. Depression Compared
to Normal Sadness - 1
Intensity: The mood change pervades all
aspects of the person and impairs social and
occupational functions
Absence of Precipitants: The mood may
arise in the absence of any discernible
precipitant or may be grossly out of
proportion to those precipitants
16. Depression Compared
to Normal Sadness - 2
Quality: The mood change is different from
that experienced in normal sadness
Associated Features:The change in mood
is accompanied by a cluster of signs and
symptoms, including cognitive and somatic
features
History: The mood change may be
preceded by a history of past episodes of
elation and hyperactivity
17. DSM-IV Major Depressive
Episode
Inclusion (must be present)
– Number: 1 core symptom plus at least 4 other
symptoms of depression
– Duration: 2 weeks
– Impairment: significant distress or social
occupational impairment
Exclusion (must be absent)
18. Cont.
Exclusion
– Not a mixed episode
Bipolar disorder
– Not due to direct physiological effect of a
substance or GMC (e.g., Hypothyroidism)
Mood disorder DTGMC
Substance-induced mood disorder
– Not better accounted (NBA) for by
bereavement
19. It Is NBA for by Bereavement If...
Symptoms persist for longer than 2 months
after loss of the loved one
Marked functional impairment
Morbid preoccupation with worthlessness
Suicidal ideation
Psychotic symptoms
Psychomotor retardation
20. Disorders With Depression As
Main Symptoms
In response to psychosocial stressor
– Bereavement
– Adjustment disorders with depressed mood
Mood disorders
– Depressive disorders (unipolar depression)
– Bipolar disorders
– Secondary mood disorders
Mood disorder DTGMC
Substance-induced mood disorder
21. Depressive Disorders
Major depressive disorder (MDD)
Dysthymic disorder
Depressive disorder not otherwise specified
(NOS)
22. DSM-IV Major Depressive
Disorder
Inclusion
– Presence of at least a Major Depressive Episode (MDE)
Exclusion
– Other mood disorders
No previous manic, hypomanic or mixed episode
– Psychotic disorders
Not better accounted by schizoaffective disorder
Not superimposed on schizophrenia, schizophreniform
disorder, delusional disorder, or psychotic disorder NOS
27. DSM-IV Dysthymic Disorder
Inclusion
– Depressed mood for 2 years plus 2 or more
following symptoms
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decision
Feelings of hopelessness
28. Cont.
Exclusion
– Other mood disorders
No MDE in 2 years (NBA chronic MDD or MDD, in partial
remission)
No manic, hypomanic or mixed episode
Not cyclothymic disorder
– Chronic psychotic disorders e.g., schizophrenia or
delusional disorder
– Secondary disorders: GMC or substance-induced
31. Depressive Disorder NOS
Premenstrual dysphoric disorder
– Regularly occurred during the last week of the luteal
phase and remitted within few days of menses
Minor depressive disorder
– 2 weeks of depression but < 5 symptoms
(insufficient number of symptoms for MDE)
Recurrent brief depressive disorder
– Depressive episode lasting from 2 days up to 2 weeks
(insufficient duration of symptoms for MDE)
32. Cont.
Postpsychotic depressive disorder of
schizophrenia
– A MDE occurs during residual phase of
schizophrenia
A MDE superimposed on delusional
disorder, psychotic disorder NOS or active
phase of schizophrenia
34. A Systematic Scheme for the Clinical
Description of Mood Disorders
The Episode
Severity Mild, moderate, or severe
Type Depressive, manic, or mixed
Special
features
Melancholic, neurotic, psychotic,
agitation, or retardation/stupor
The Course Unipolar or bipolar
Etiology Predominantly reactive or endogenous
Oxford Textbook of Psychiatry, 3rd edition, pg 209
35. Classification of Depressive
Disorders
ICD-10 DSM-IV
Depressive episode
Mild, moderate, severe, or severe with
psychosis
Major depressive episode
Mild, moderate, severe, or severe with
psychosis
Other depressive episode
Atypical depression
Recurrent depressive episode Major depressive disorder
recurrent
Persistent mood disorders
Cyclothymia and dysthymia
Dysthymic disorder
Other mood disorders
Recurrent brief depression
Depressive disorder NOS
Recurrent brief depression
Oxford Textbook of Psychiatry, 3rd edition, pg 208
36. Clinical Features of Melancholic
and Somatic Depression
Melancholic features (DSM-IV)
– Loss of interest or pleasure in usual activities*
– Lack of reactivity to pleasurable stimuli*
Plus at least three of the following
– Distinct quality of mood (unlike normal sadness)
– Morning worsening of mood*
– Early morning waking*
– Psychomotor agitation or retardation*
– Significant anorexia or weight loss*
– Excessive guilt
– Marked loss of libido* (ICD-10)
*Somatic symptoms of depression in ICD-10 (at least 4 required for diagnosis)
Oxford Textbook of Psychiatry, 3rd edition, pg 205
37. Psychotic Features
Severe with psychotic features
mood-incongruent
mood-congruent
Severe without psychotic features
Moderate
Mild
38. Cont.
Mood-congruent psychotic features
Delusions of guilt
Delusions of deserved punishment
Nihilistic delusions (Cotard’s syndrome)
Somatic (hypochondriacal) delusions
Delusions of poverty
Auditory hallucinations – usually transient, not
elaborate, repetitive words and phrases
39. Cont.
Mood-incongruent psychotic features
– Less common
– Associated with poorer prognosis
– Persecutory delusions (without depressive
themes that he/she should be persecuted)
– Delusions of thought insertion/broadcasting or
delusion of control
40. Other Features
Prominent features
Agitated depression Agitation
Retarded depression Psychomotor retardation
Depressive stupor Stupor, may have catatonia
Masked depression Somatic complaints
Atypical depression Mood reactivity, weight gain,
increase appetite,
hypersomnia, interpersonal
rejection sensitivity
41. Epidemiology of Bipolar and
Unipolar Disorder
Bipolar
disorder
Unipolar
disorder
Lifetime risk About 1% 5%-10%
Sex ratio (M:F) 1:1 1:2
Average age of
onset
21 yrs 27 yrs
Oxford Textbook of Psychiatry, 3rd edition, pg 212
42. Some Etiological Factors in
Major Depression
Genetic
Family history of depression
Early development
Parental discord in childhood
Childhood abuse
Personality
Neuroticism
Environmental factors
Recent stressful life events
Lack of social support
Oxford Textbook of Psychiatry, 3rd edition, pg 213
48. Neurotransmitters in Mood Disorder
Dopamine Norepinephrine
Serotonin
drive zeal
motivation
alertness
energy
mood
GABA
Enkephalins
Endorphins
Na channels
Glutamate
impulse
49. Phase of Treatment
Phase Aim
Acute Reduction of symptoms
Continuation Prevention of relapse
Maintenance
(prophylaxis)
Prevention of recurrence
50. 5-4 Stahl S M, Essential
Psychopharmacology (2000)
acute
6 - 12 weeks
continuation
4-9 months
maintenance
1 or more years
TIME
DEPRESSION
NORMAL
MOOD RELAPSE RECURRENCE
51. Type of Treatment
Pharmacotherapy
Antidepressant – TCA, SSRI, MAOI
Physical
Electroconvulsive therapy (ECT)
Psychotherapy
Dynamic, marital, interpersonal, CBT
Other
Sleep deprivation, bright light therapy
52. Some Problems and Treatment
Patient Problem Treatment
Suicidal
Immediate risk of
suicide
Pharmacotherapy ~ 2 weeks
ECT has faster onsetPostpartum
Risk of infanticide,
poor baby care
Stupor Poor oral intake
Psychotic Psychotic Add antipsychotics
Elderly
Diagnosis, prone to
side-effects
Cautious of drug interaction
Less anticholinergic s/effect
54. Case Scenario
30 years old female, para 4. Just delivered a
baby boy 2 months ago. Complaint of
feeling sad, lethargic, loss of appetite and
terminal insomnia since 2 weeks after
delivery. Past 2 weeks condition worsen –
insist that the baby should not be born as he
would live in poverty. She also heard voices
repeatedly condemning her for not being a
good mother.
55. Cont.
She had similar episodes during the
previous childbirth but resolved without
hospital treatment in a few months time.
Husband, a lorry driver, frequently went for
outstation for days. Modest income and
does not help much with bringing-up of the
children. Family history: her mother died of
suicide after a marital discord.
56. Symptom Syndrome
Symptoms
– Sad
– Insomnia
– Loss of appetite
– Fatigue
– Hallucinations and ?delusions
Duration
– Onset 2 weeks of childbirth
– Duration 6 weeks
Impairment
57. Syndrome Diagnosis
Cross sectionally
– Does it qualify as MDE?
Sufficient number, duration and impairment
Not mixed episode, no secondary/organic causes,
NBA for by bereavement
Longitudinally
– Does it better accounted by another mental
disorder?
Is there previous mood episodes?
Is there underlying psychotic disorders?