10-3-05 219.ppt 5 108.ppt "Iceberg" Phenomenon The overwhelming majority of patients with depressive disorders are seen by primary care physicians (Watts, 1966). In some countries, specialists treat less than 5% of all patients with depressive disorders (Madianos & Stefanis, 1992). WPA/PTD Educational Program on Depressive Disorders
Outcome of Depression International Network (ODIN) study: n=8.764 (Spain, Finland, Norway, Ireland, UK) Prevalence for women was 10.05% and for men 6.61% The UN estimates the total European population at 729 million
Depression is a common and burdensome disease. Most women with depression will not present to mental health professionals and will not complain of mood symptoms. One in 10 women seeking care in an obstetrics and gynecology practice for routine women’s health problems are silently suffering with an illness they are hesitant to bring up. Fortunately, depression can be ruled out by asking about 2 symptoms and ruled in if 5 are present. Patients diagnosed with depression must be screened for suicidality and, if positive, referred to psychiatric emergency services immediately. Patients who are diagnostic or therapeutic challenges can be referred to a specific consulting psychiatrist. As specialists who lead the effort to improve women’s health, Ob/Gyns must accept the responsibility to diagnose and treat depression in women.
Mood DisordersMood Disorders
Seen By Psychiatrists
WPA/PTD Educational Program on Depressive Disorders
Depressed PatientsDepressed Patients
The Unmet Needs in DepressionThe Unmet Needs in Depression
Major cause of disability worldwide (WHO):Major cause of disability worldwide (WHO):11
1. Murray, CJ, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality
and Disability from Diseases, Injuries, & Risk Factors in 1990 Projected to 2020. Cambridge, MA: 1996.
Rank 2000 2020 (Estimated)
1 Lower respiratory infections Ischemic heart disease
2 Perinatal conditions Unipolar major depression
3 HIV/AIDS Road traffic accidents
4 Unipolar major depression Cerebrovascular disease
5 Diarrheal diseases COPD
Mood DisordersMood Disorders
Depressive Disorders:Depressive Disorders:
– Major Depressive Disorder.Major Depressive Disorder.
– Dysthymic Disorder.Dysthymic Disorder.
Bipolar Disorders:Bipolar Disorders:
– Bipolar I Disorder.Bipolar I Disorder.
– Bipolar II Disorder.Bipolar II Disorder.
– Cyclothymic Disorder.Cyclothymic Disorder.
Major Depressive DisorderMajor Depressive Disorder
Lifetime prevalence unipolarLifetime prevalence unipolar
– Up to 21% in women.Up to 21% in women.
– 13% in men.13% in men.
Typical age of onset:Typical age of onset:
– 20s, but can occur at any time.20s, but can occur at any time.
Symptoms of DepressionSymptoms of Depression
A loss of interest for at least two weeks or more,A loss of interest for at least two weeks or more,
accompanied by five or more psychological, somatic oraccompanied by five or more psychological, somatic or
behavioral symptoms:behavioral symptoms:
•• Lack of energy.Lack of energy.
•• Sleep/appetite disturbances.Sleep/appetite disturbances.
•• Thoughts of suicide/death.Thoughts of suicide/death.
•• Psychomotor retardation.Psychomotor retardation.
•• Loss of concentration.Loss of concentration.
Mood SymptomsMood Symptoms
Persistent sad, depressed mood.Persistent sad, depressed mood.
Loss of interest or pleasure inLoss of interest or pleasure in
previously enjoyable activities.previously enjoyable activities.
DSM-IV criteria specify thatDSM-IV criteria specify that
person must have 1 of above plusperson must have 1 of above plus
4 additional sx for at least 24 additional sx for at least 2
Physical SymptomsPhysical Symptoms
Sleep disturbance:Sleep disturbance:
– Too much or too little.Too much or too little.
Loss of energy or fatigue.Loss of energy or fatigue.
Appetite disturbance/weight change:Appetite disturbance/weight change:
– Loss of appetite or increase in appetite.Loss of appetite or increase in appetite.
Changes in activity level:Changes in activity level:
– Psychomotor retardation or agitation.Psychomotor retardation or agitation.
Cognitive SymptomsCognitive Symptoms
Difficulty concentrating,Difficulty concentrating,
thinking, and making decisions.thinking, and making decisions.
Feelings of worthlessness, guilt,Feelings of worthlessness, guilt,
or hopelessness.or hopelessness.
Recurrent thoughts of death orRecurrent thoughts of death or
Suicide Risk FactorsSuicide Risk Factors
Prior history of suicide.Prior history of suicide.
Pre-existing psychiatric disorder.Pre-existing psychiatric disorder.
Depression and hopelessness.Depression and hopelessness.
Advanced disease with poor prognosis.Advanced disease with poor prognosis.
Loss of control and helplessness.Loss of control and helplessness.
Exhaustion and fatigue.Exhaustion and fatigue.
Chronic pain.Chronic pain.
Severe without psychotic features.Severe without psychotic features.
Severe with psychotic features.Severe with psychotic features.
Partial remission.Partial remission.
Full remission.Full remission.
Additional SpecifiersAdditional Specifiers
With catatonic features.With catatonic features.
With melancholic features.With melancholic features.
With atypical features.With atypical features.
With postpartum onset.With postpartum onset.
With seasonal pattern.With seasonal pattern.
Melancholic FeaturesMelancholic Features
Doesn’t feel better even when pleasant orDoesn’t feel better even when pleasant or
good things happen.good things happen.
Depression worse in the morning.Depression worse in the morning.
Early morning awakenings.Early morning awakenings.
Psychomotor retardation or agitation.Psychomotor retardation or agitation.
Inappropriate guilt.Inappropriate guilt.
Dysthymic DisorderDysthymic Disorder
Less severe but more chronicLess severe but more chronic
(Chronic “low grade” depression)(Chronic “low grade” depression)..
Depressed mood, plus 2 additional sx:Depressed mood, plus 2 additional sx:
– Poor appetite or overeating.Poor appetite or overeating.
– Insomnia or hypersomnia.Insomnia or hypersomnia.
– Low energy or fatigue.Low energy or fatigue.
– Low self-esteem.Low self-esteem.
– Poor concentration or difficulty making decisions.Poor concentration or difficulty making decisions.
– Feelings of hopelessness.Feelings of hopelessness.
Symptoms must have lasted for at least 2 yrs.Symptoms must have lasted for at least 2 yrs.
Never without symptoms for longer than 2 months.Never without symptoms for longer than 2 months.
Bipolar I DisorderBipolar I Disorder
Often called manic depression.Often called manic depression.
Typically involves episodes ofTypically involves episodes of
major depression and mania.major depression and mania.
Lifetime prevalence is 1% for bothLifetime prevalence is 1% for both
men and women.men and women.
Typical age of onset is late teens-Typical age of onset is late teens-
early 20s.early 20s.
Symptoms of Manic EpisodesSymptoms of Manic Episodes
Elevated, expansive or irritable mood for atElevated, expansive or irritable mood for at
least 1 week, plus 3 additional symptoms.least 1 week, plus 3 additional symptoms.
Inflated self-esteem/grandiosity.Inflated self-esteem/grandiosity.
Decreased need for sleep (3 hrs.).Decreased need for sleep (3 hrs.).
Unusual talkativeness or pressured speech.Unusual talkativeness or pressured speech.
Flight of ideas/racing thoughts.Flight of ideas/racing thoughts.
Marked distractibility.Marked distractibility.
Increased activity (Hyperactivity).Increased activity (Hyperactivity).
Excessive involvement in pleasurable activities.Excessive involvement in pleasurable activities.
Course of Bipolar I DisorderCourse of Bipolar I Disorder
There is great variability in cycle time.There is great variability in cycle time.
35% of individuals go through only 135% of individuals go through only 1
cycle in 5 years.cycle in 5 years.
1% of individuals go through 1 cycle1% of individuals go through 1 cycle
every 3 months.every 3 months.
Rapid cycling: 4 or more cycles/ year.Rapid cycling: 4 or more cycles/ year.
Other Bipolar DisordersOther Bipolar Disorders
Bipolar II:Bipolar II:
– Alternate between hypomanic and majorAlternate between hypomanic and major
depressive episodes.depressive episodes.
Cyclothymic Disorder:Cyclothymic Disorder:
– Alternate between depressive (not MDE)Alternate between depressive (not MDE)
and hypomanic episodes for at least 2 yrs.and hypomanic episodes for at least 2 yrs.
– Never without symptoms for longer than 2Never without symptoms for longer than 2
Hypomanic EpisodeHypomanic Episode
Elevated, expansive or irritable moodElevated, expansive or irritable mood
for at least 4 days.for at least 4 days.
Symptoms similar to manic episode,Symptoms similar to manic episode,
except no marked impairment/except no marked impairment/
COMORBID DISORDERSCOMORBID DISORDERS
Substance Abuse – At least 60%.Substance Abuse – At least 60%.
Alcohol, Cocaine, THC.Alcohol, Cocaine, THC.
Effect – More mixed and rapid cycling,Effect – More mixed and rapid cycling,
poorer response to Lithium, slower timepoorer response to Lithium, slower time
to recovery and more lifetimeto recovery and more lifetime
Narcissistic PD.Narcissistic PD.
Borderline PD.Borderline PD.
20-30% OCD or Panic Disorder.20-30% OCD or Panic Disorder.
1. Genetics1. Genetics
Twin & Adoption Studies:Twin & Adoption Studies:
StudiesStudies show genetic link for mood disorders (Link isshow genetic link for mood disorders (Link is
stronger for bipolar disorder than unipolarstronger for bipolar disorder than unipolar
Concordance Rates:Concordance Rates:
Likelihood that if one member of pair has disease, otherLikelihood that if one member of pair has disease, other
member will also have diseasemember will also have disease
Unipolar depression:Unipolar depression:
- MZ twins = 36% & DZ twins = 17%.- MZ twins = 36% & DZ twins = 17%.
Bipolar disorder:Bipolar disorder:
2. Neurotransmitters2. Neurotransmitters
Depression is associated with low levels of serotonin inDepression is associated with low levels of serotonin in
relation to norepinephrine and dopamine:relation to norepinephrine and dopamine:
– Primary function of serotonin is to regulate ourPrimary function of serotonin is to regulate our
emotional reactions.emotional reactions.
– When levels of serotonin are low, we become moreWhen levels of serotonin are low, we become more
impulsive & our moods swing more wildly.impulsive & our moods swing more wildly.
Medications that treat depression increase serotoninMedications that treat depression increase serotonin
and/or norepinephrine in the synapse within a fewand/or norepinephrine in the synapse within a few
3. Endocrine System3. Endocrine System
Depression can be a symptom of someDepression can be a symptom of some
endocrine disorders:endocrine disorders: HHypothyroidism &ypothyroidism &
Cushing’s syndromeCushing’s syndrome..
HPA axis:HPA axis: HHypothalamus-Pituitary-Adrenalypothalamus-Pituitary-Adrenal..
Hypothalamus sends signals to pituitaryHypothalamus sends signals to pituitary
gland which sends signals to adrenalgland which sends signals to adrenal
gland to secrete hormones related togland to secrete hormones related to
stress response:stress response:
– 50% of depressed individuals show elevated50% of depressed individuals show elevated
levels of cortisol.levels of cortisol.
4. Circadian Rhythms4. Circadian Rhythms
Mood disorders are caused by disturbance in circadianMood disorders are caused by disturbance in circadian
– Circadian rhythms (sleep-wake, temperature,Circadian rhythms (sleep-wake, temperature,
hunger) are regulated by hypothalamus.hunger) are regulated by hypothalamus.
– Exposure to light affects circadian rhythmsExposure to light affects circadian rhythms
(suppresses melatonin).(suppresses melatonin).
– Prevalence of seasonal affective disorder is higher inPrevalence of seasonal affective disorder is higher in
extreme northern & southern latitudes.extreme northern & southern latitudes.
– Depriving depressed patients of sleep canDepriving depressed patients of sleep can
temporarily reduce their depression.temporarily reduce their depression.
– Extended bouts of insomnia triggers manic episodes.Extended bouts of insomnia triggers manic episodes.
6. Stress6. Stress
Stressful life events are strongly related to the onsetStressful life events are strongly related to the onset
of mood disorders:of mood disorders:
– 20-50% of individuals who experience stressful life events20-50% of individuals who experience stressful life events
become depressed.become depressed.
– Same stressors that are associated with depression areSame stressors that are associated with depression are
associated with other disorders.associated with other disorders.
– Approximately 1/3 of the association between stressful lifeApproximately 1/3 of the association between stressful life
events and depression is due to the tendency of people whoevents and depression is due to the tendency of people who
are vulnerable to depression to place themselves in high-are vulnerable to depression to place themselves in high-
risk stressful environments.risk stressful environments.
– Social support seems to reduce risk for developingSocial support seems to reduce risk for developing
depression when exposed to stress.depression when exposed to stress.
PSYCHOSOCIAL FACTORSPSYCHOSOCIAL FACTORS
OF DEPRESSIONOF DEPRESSION
Death and dying.Death and dying.
Chronic pain.Chronic pain.
Loss of role.Loss of role.
Family conflict.Family conflict.
Lifelong issues.Lifelong issues.
7. Learned Helplessness7. Learned Helplessness
People become anxious & depressed when theyPeople become anxious & depressed when they
make an attribution that they have no controlmake an attribution that they have no control
over the stress in their lives.over the stress in their lives.
Depressive Attributional Style:Depressive Attributional Style:
* Attribution: The way in which people* Attribution: The way in which people
assign causes to events in their lives.assign causes to events in their lives.
* People who are depressed tend to make* People who are depressed tend to make
attributions that are:attributions that are: (Internal, Stable & Global).(Internal, Stable & Global).
* Sense of hopelessness is important.* Sense of hopelessness is important.
8. Negative Cognitive Style8. Negative Cognitive Style
Tendency to interpret everyday events in a negativeTendency to interpret everyday events in a negative
Reflects cognitive errors:Reflects cognitive errors:
– All or nothing.All or nothing.
– Arbitrary inference: Selective attention to negative aspects.Arbitrary inference: Selective attention to negative aspects.
Make negative interpretations about:Make negative interpretations about:
(Self – World – Future).(Self – World – Future).
Depressive cognitions emerge from distorted &Depressive cognitions emerge from distorted &
probably automatic methods of processingprobably automatic methods of processing
9. Cognitive Vulnerability9. Cognitive Vulnerability
5-year longitudinal study of college students using:5-year longitudinal study of college students using:
– Questionnaires: measured dysfunctional attitudesQuestionnaires: measured dysfunctional attitudes
and hopelessness attributionsand hopelessness attributions
– Subjects were assessed every several months forSubjects were assessed every several months for
next 5 years for symptoms of depressionnext 5 years for symptoms of depression
– Negative cognitive styles do indicate a vulnerabilityNegative cognitive styles do indicate a vulnerability
to later depressionto later depression
– Subjects who scored high on measures of cognitiveSubjects who scored high on measures of cognitive
vulnerability were more likely to experience latervulnerability were more likely to experience later
depression (17% vs. 1%)depression (17% vs. 1%)
Hospitalization for mania, severeHospitalization for mania, severe
depression & suicide.depression & suicide.
Mood stabilizers, antipsychotics andMood stabilizers, antipsychotics and
ECT – most effective treatment.ECT – most effective treatment.
Supportive psychotherapy and CBT.Supportive psychotherapy and CBT.
Lifestyle change.Lifestyle change.
Substance abuse treatment.Substance abuse treatment.
50% attempt Suicide.50% attempt Suicide.
Untreated depression get 10 ms or more to recover.Untreated depression get 10 ms or more to recover.
75% have recurrence.75% have recurrence.
50% full recovery.50% full recovery.
30% partial remission.30% partial remission.
20% tend to be Chronic.20% tend to be Chronic.
20-30% of Dysthymic Disorder go to MDD or BD.20-30% of Dysthymic Disorder go to MDD or BD.
Serious consequences:Serious consequences:
– Impaired social and occupational functioning.Impaired social and occupational functioning.
– Increased co-morbidity of psychiatric & medical conditions.Increased co-morbidity of psychiatric & medical conditions.
– Increased risk of mortality among depressed individuals.Increased risk of mortality among depressed individuals.
Mood disorders are chronic & recurrent disorders.Mood disorders are chronic & recurrent disorders.
Mood disorders are common.Mood disorders are common.
Many peoples suffer needlessly because their moodMany peoples suffer needlessly because their mood
disorder is not diagnosed and treated.disorder is not diagnosed and treated.
Diagnosing mood disorders is straightforward.Diagnosing mood disorders is straightforward.
Drugs are effective and practical.Drugs are effective and practical.
Doctors should take the lead in recognizing andDoctors should take the lead in recognizing and
treating mood disorders.treating mood disorders.
““AFTER ALL,AFTER ALL,
THERE ISTHERE IS
NOTHING ASNOTHING AS
INTERESTING ASINTERESTING AS
PEOPLE, AND ONEPEOPLE, AND ONE
CAN NEVER STUDYCAN NEVER STUDY
THEM ENOUGH”THEM ENOUGH”
VAN GOGHVAN GOGH
Vincent van Gogh, who himself
suffered from depression and
committed suicide, painted this
picture in 1890 of a man that can
symbolize the desperation and
hopelessness felt in depression.