Ten Leading Causes ofDisability in the World           Type of Disability        Cost (in   Cumulative                    ...
Episode                             Disorder*Major depression episode    *Major depression  disorder*Major depression epis...
“If I had __________, I’d     be depressed to.”
Definitions• Mood - a person’s sustained emotional state• Affect – the outward manifestation of a  person’s feelings, tone...
Major Depression• Syndromal classification with disturbances  of mood, neurovegetative and cognitive  functioning
Major DepressionAt least 5 of the following symptoms present for at least 2 weeks (either #1 or #2 must be present): 1) de...
Major Depression5) psychomotor retardation or agitation6) decreased energy7) feeling of worthlessness or inappropriate    ...
Major Depression• Symptoms cause marked distress and/or impairment in social or occupational functioning.• No evidence of ...
Bereavement and   Late Life Depression• 25 – 35% of widows/widowers meet diagnostic criteria for major depressive disorder...
Subtypes of Depression• Atypical  Reverse neurovegetative symptoms  Mood reactivity  Hypersensitivity to rejection  MA...
Subtypes of Depression    Psychotic (~10% of all MDD)      • Delusions common, may have        hallucinations      • Delu...
Subtypes of Depression    Melancholic      • No mood reactivity      • Anhedonia      • Prominent neurovegetative        ...
Subtypes of Depression    Seasonal      • Onset in Fall, remission in Spring      • Hypersomnia is typical      • Less re...
Subtypes of Depression    Catatonic      • Motoric immobility (catalepsy)      • Mutism      • Ecolalia or echopraxia
EpidemiologyPoint prevalence    6 – 8% in women    3 – 4% in menLifetime prevalence     20% in women     10% in men
EpidemiologyAge of Onset     Throughout the life cycle, typically from  the mid 20’s through the 50’s with a peak  age of...
EpidemiologyGenetics More prevalent in first degree relatives      3-5x the general population risk Concordance is great...
EtiologyOriginal, clearly over simplistic theories   regarding norepinephrine and   serotonin Deficiency states         d...
Problems with initial theories Inconsistentfindings when studying  measures of these systems: MHPG (3  methoxy 4 hydroxyp...
Receptor theory more useful Antidepressant treatment causes a down regulation in central adrenergic and serotonergic rece...
Neuroendocrine Hyperactivity    of HPA axis:  – Elevated cortisol  – Nonsuppression of cortisol following dexamethasone  ...
Functional Neuroimaging (PET,SPECT)demonstrates decreased metabolic activity in    Dorsal   prefontal cortex     – Antero...
Psychosocial Risk  Factors  – Poor social supports  – Early parental loss  – Introversion  – Female gender  – Recent stre...
Psychosocial Cognitive Theory  – Patients have distorted perceptions    and thoughts of themselves, the world    around t...
Secondary Causes of           Depression Toxic Endocrine Vascular Neurologic Nutritional Neoplastic Traumatic Infe...
Depression – Differential         DiagnosisOther Mood Disorders Adjustment    Disorder with Depressed Mood   – Maladaptiv...
TreatmentBiologic Tricylclic antidepressants Monoamine oxidase inhibitors Second generation antidepressants  – SSRI’s, ...
TreatmentPsychosocial Treatments Education Specific pscychotherapies Vocational training Exercise
TreatmentWhen to Refer? Question regarding suicide risk Presence of psychotic symptoms Past history of mania Lack of r...
TreatmentCourse One episode – 50% chance of reoccurence Two episodes – 70% chance of reoccurence Three or more episodes...
Dysthymic DisorderCharacteristics Chronically depressed mood for most of the day, more  days than not, for at least two y...
Dysthymic Disorder Never  without depressive symptoms for over 2  months No evidence of an unequivocal Major Depressive ...
Epidemiology More  prevalent in women, 4% prevalence  in women, 2% in men Onset is usually in childhood, adolescence  or...
Differential Diagnosis Other   mood disorders Mood  disorder due to a general medical condition
Treatment Ifno superimposed Major Depression  – Psychotherapy Some  evidence suggest responsiveness to  antidepressant m...
CoursePrognosis is not as good as MajorDepression in terms of total symptomsremission
Bipolar DisorderCharacteristics of a Manic Episode A distinct period of abnormally and persistently  elevated, expansive ...
Characteristics (Cont.)– Distractability, i.e. attention too easily drawn to  unimportant or irrelevant external stimuli– ...
Characteristics (Cont.) Mood   disturbance sufficiently severe to cause marked  impairment in occupational functioning or...
Presentations of Bipolar Disorder   Manic   Depressed   Mixed
Types TypeI - manic/mixed episode +/- major depressive episode TypeII - hypomanic episode + major depressive episode
EpidemiologyLifetime prevalence Type I - 0.7 - 0.8% Type II - 0.4 - 0.5%  – Equal in males and females  – Increased prev...
Genetics Greaterrisk in first degree relatives (4-14 times risk) Concordance in monozygotic twins >85% Concordance in d...
Secondary Causes of ManiaToxins Drugs   of Abuse   – Stimulants (amphetamines, cocaine)   – Hallucinogens (LCD, PCP) Pre...
Secondary Causes of Mania         (Cont.)Infectious Neurosyphilis HIVEndocrine Hypothyroidism Cushing’s   DiseaseCyclo...
Treatment Education and Support Medication    1. Lithium    2. Carbamazepine    3. Valproate    4. Lamotrigine    5. ECT
Course Acute   Episode  – Manic - 5 weeks  – Depressed - 9 weeks  – Mixed - 14 weeks Long   Term  – Variable - most cove...
Cyclothymic DisorderCharacteristics For at least two years (one for children and  adolescents) presence of numerous Hypom...
Characteristics (Cont.) No  clear evidence of a Major Depressive Disorder,  or Manic Episode during the first two years o...
Epidemiology Lifetimeprevalence 0.4 – 1.0 %  same for males and females Age of onset  – Usually in adolescence or early ...
Cyclothymic DisorderSecondary causes of cyclothymic disorder Bipolar        Disorder Mood disorders due to a general med...
Episode                             Disorder*Major depression episode    *Major depression  disorder*Major depression epis...
12 22-2012 depression-2
12 22-2012 depression-2
12 22-2012 depression-2
12 22-2012 depression-2
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12 22-2012 depression-2

  1. 1. Ten Leading Causes ofDisability in the World Type of Disability Cost (in Cumulative DALYs) % of CostUnipolar major depression 42,972 10.3Tuberculosis 19,673 14.9Road traffic accidents 19,625 19.6Alcohol use 14,848 23.2Self-inflicted injuries 14,645 26.7Manic-depressive (bipolar) illness 13,189 29.8War 13,134 32.9Violence 12,955 36.0Schizophrenia 12,542 39.0Iron deficiency anemia 12,511 42.0
  2. 2. Episode Disorder*Major depression episode *Major depression disorder*Major depression episode+ *Bipolar disorder, Type I manic/mixed episode*Manic/mixed episode *Bipolar disorder, Type I*Major depressive episode+ *Bipolar disorder, Type II hypomanic episode*Chronic subsyndromal *Dysthymic Disorder depression*Chronic fluctuations between subsyndromal *Cyclothymic disorder depression & hypomania
  3. 3. “If I had __________, I’d be depressed to.”
  4. 4. Definitions• Mood - a person’s sustained emotional state• Affect – the outward manifestation of a person’s feelings, tone, or mood
  5. 5. Major Depression• Syndromal classification with disturbances of mood, neurovegetative and cognitive functioning
  6. 6. Major DepressionAt least 5 of the following symptoms present for at least 2 weeks (either #1 or #2 must be present): 1) depressed mood 2) anhedonia – loss of interest or pleasure 3) change in appetite 4) sleep disturbance
  7. 7. Major Depression5) psychomotor retardation or agitation6) decreased energy7) feeling of worthlessness or inappropriate guilt8) diminished ability to think or concentrate9) recurrent thoughts of death or suicidalideation
  8. 8. Major Depression• Symptoms cause marked distress and/or impairment in social or occupational functioning.• No evidence of medical or substance- induced etiology for the patient’s symptoms.• Symptoms are not due to a normal reaction to the death of a loved one.
  9. 9. Bereavement and Late Life Depression• 25 – 35% of widows/widowers meet diagnostic criteria for major depressive disorder at 2 months.• ~15% of widows/widowers meet diagnostic criteria for major depressive disorder at one year.• This figure remains stable throughout the second year.
  10. 10. Subtypes of Depression• Atypical Reverse neurovegetative symptoms Mood reactivity Hypersensitivity to rejection MAO-I’s and SSRI’s are more effective treatments
  11. 11. Subtypes of Depression  Psychotic (~10% of all MDD) • Delusions common, may have hallucinations • Delusions usually mood congruent • Combined antidepressant and antipsychotic therapy or ECT is necessary
  12. 12. Subtypes of Depression  Melancholic • No mood reactivity • Anhedonia • Prominent neurovegetative disturbance • More likely to respond to biological treatments
  13. 13. Subtypes of Depression  Seasonal • Onset in Fall, remission in Spring • Hypersomnia is typical • Less responsive to medications • A.M. light therapy (>2,500 lux) is effective
  14. 14. Subtypes of Depression  Catatonic • Motoric immobility (catalepsy) • Mutism • Ecolalia or echopraxia
  15. 15. EpidemiologyPoint prevalence 6 – 8% in women 3 – 4% in menLifetime prevalence 20% in women 10% in men
  16. 16. EpidemiologyAge of Onset Throughout the life cycle, typically from the mid 20’s through the 50’s with a peak age of onset in the mid 30’s
  17. 17. EpidemiologyGenetics More prevalent in first degree relatives 3-5x the general population risk Concordance is greater in monozygotic than dizygotic twins Increased prevalence of alcohol dependence in relatives
  18. 18. EtiologyOriginal, clearly over simplistic theories regarding norepinephrine and serotonin Deficiency states depression States of excess mania
  19. 19. Problems with initial theories Inconsistentfindings when studying measures of these systems: MHPG (3 methoxy 4 hydroxyphenolglycol) and 5HIAA (5 hydroxy indoleacetic acid) in the urine and CSF. Treatments block monoamine uptake acutely, however the positive effects occur in 2-4 weeks.
  20. 20. Receptor theory more useful Antidepressant treatment causes a down regulation in central adrenergic and serotonergic receptors – This change corresponds temporally to the antidepressant response
  21. 21. Neuroendocrine Hyperactivity of HPA axis: – Elevated cortisol – Nonsuppression of cortisol following dexamethasone – Hypersecretion of CRF Blunting of TSH response to TRH Blunting of serotonin mediated increase in plasma prolactin Blunting of the expected increase in plasma growth hormone response to alpha-2 agonists
  22. 22. Functional Neuroimaging (PET,SPECT)demonstrates decreased metabolic activity in  Dorsal prefontal cortex – Anterolateral (concentration, cognitive processing) – Cingulate (regulation of mood and affect)  Subcortical – Caudate (psychomotor changes)
  23. 23. Psychosocial Risk Factors – Poor social supports – Early parental loss – Introversion – Female gender – Recent stressor (especially medical illness)
  24. 24. Psychosocial Cognitive Theory – Patients have distorted perceptions and thoughts of themselves, the world around them and the future  Possible to treat by restructuring
  25. 25. Secondary Causes of Depression Toxic Endocrine Vascular Neurologic Nutritional Neoplastic Traumatic Infectious Autoimmune
  26. 26. Depression – Differential DiagnosisOther Mood Disorders Adjustment Disorder with Depressed Mood – Maladaptive and excessive response to stress, difficulty functioning, need support not medicines, resolve as stress resolves – Dysthymic Disorder – Bipolar Disorder Other Psychotic Disorders – if psychotic subtype Personality Type – “glass is half empty type” overall pessimistic, depressed outlook. Chronic and longstanding with no change in function.
  27. 27. TreatmentBiologic Tricylclic antidepressants Monoamine oxidase inhibitors Second generation antidepressants – SSRI’s, Venlafaxine, bupropion, martazapine Electoconvulsive therapy
  28. 28. TreatmentPsychosocial Treatments Education Specific pscychotherapies Vocational training Exercise
  29. 29. TreatmentWhen to Refer? Question regarding suicide risk Presence of psychotic symptoms Past history of mania Lack of response to adequate medication trial
  30. 30. TreatmentCourse One episode – 50% chance of reoccurence Two episodes – 70% chance of reoccurence Three or more episodes - >90% chance of reoccurence
  31. 31. Dysthymic DisorderCharacteristics Chronically depressed mood for most of the day, more days than not, for at least two years. Can be irritable mood in children and adolescents for 1 year While depressed, presence of at least two of the following – Poor appetite or overeating – Sleep disturbance – Low energy or fatigue – Low self esteem – Poor concentration – Feelings of hopelessness
  32. 32. Dysthymic Disorder Never without depressive symptoms for over 2 months No evidence of an unequivocal Major Depressive Episode during the first two years of the disturbance (1 year in children and adolescents) No manic or hypermanic episodes Not superimposed on a chronic psychotic disorder Not due to the direct physiologic affects of a substance or a general medical condition
  33. 33. Epidemiology More prevalent in women, 4% prevalence in women, 2% in men Onset is usually in childhood, adolescence or early adulthood Often is a superimposed Major Depression High prevalence of substance abuse in this group
  34. 34. Differential Diagnosis Other mood disorders Mood disorder due to a general medical condition
  35. 35. Treatment Ifno superimposed Major Depression – Psychotherapy Some evidence suggest responsiveness to antidepressant medication
  36. 36. CoursePrognosis is not as good as MajorDepression in terms of total symptomsremission
  37. 37. Bipolar DisorderCharacteristics of a Manic Episode A distinct period of abnormally and persistently elevated, expansive or irritable mood During the period of mood disturbance, at least three of the following symptoms have persisted (four if the mood is only irritable) and have been persistent to a significant degree – Inflated self esteem or grandiosity – Decreased need for sleep – More talkative than usual or pressure to keep talking – Flight of ideas or subjective experience that thoughts are racing
  38. 38. Characteristics (Cont.)– Distractability, i.e. attention too easily drawn to unimportant or irrelevant external stimuli– Increase in goal-directed activity or psychomotor agitation– Excessive involvement in pleasurable activities which have a high potential for painful consequences, e.g. unrestrained buying sprees, sexual indiscretions, or foolish business investments
  39. 39. Characteristics (Cont.) Mood disturbance sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relations with others, or to necessitate hospitalization to prevent harm to self or others At no time during the disturbance have there been delusions or hallucinations for as long as two weeks in the absence of prominent mood symptoms Not superimposed on schizophrenia, schizophreniform disorder, or delusional disorder or psychotic disorder NOS The disturbance is not due to the physiologic effects of a substance or general medical disorder
  40. 40. Presentations of Bipolar Disorder  Manic  Depressed  Mixed
  41. 41. Types TypeI - manic/mixed episode +/- major depressive episode TypeII - hypomanic episode + major depressive episode
  42. 42. EpidemiologyLifetime prevalence Type I - 0.7 - 0.8% Type II - 0.4 - 0.5% – Equal in males and females – Increased prevalence in upper socioeconomic classes Age of Onset – Usually late adolescence or early adulthood. However some after age 50. Late onset is more commonly Type II.
  43. 43. Genetics Greaterrisk in first degree relatives (4-14 times risk) Concordance in monozygotic twins >85% Concordance in dyzygotic twins – 20%
  44. 44. Secondary Causes of ManiaToxins Drugs of Abuse – Stimulants (amphetamines, cocaine) – Hallucinogens (LCD, PCP) Prescription Medications – Common: antidepressants, L-dopa, corticosteroidsNeurologic Right-sided CVA Right frontotemporal tumors Huntington’s Disease Multiple Sclerosis
  45. 45. Secondary Causes of Mania (Cont.)Infectious Neurosyphilis HIVEndocrine Hypothyroidism Cushing’s DiseaseCyclothymic DisorderOther Psychotic Disorders
  46. 46. Treatment Education and Support Medication 1. Lithium 2. Carbamazepine 3. Valproate 4. Lamotrigine 5. ECT
  47. 47. Course Acute Episode – Manic - 5 weeks – Depressed - 9 weeks – Mixed - 14 weeks Long Term – Variable - most cover fully – Mean number of lifetime episodes 8-9
  48. 48. Cyclothymic DisorderCharacteristics For at least two years (one for children and adolescents) presence of numerous Hypomanic Episodes and numerous periods with depressed mood or loss of interest or pleasure that did not meet criterion A of a Major Depressive Episode During a two year period (one year in children and adolescents) of the disturbance, never without hypomanic or depressive symptoms for more than a two month time
  49. 49. Characteristics (Cont.) No clear evidence of a Major Depressive Disorder, or Manic Episode during the first two years of the disturbance (or one year for children and adolescents) Not superimposed on a chronic psychotic disorder, such as schizophrenia or Delusional Disorder Not due to the direct physiologic affects of a substance or a general medical condition
  50. 50. Epidemiology Lifetimeprevalence 0.4 – 1.0 % same for males and females Age of onset – Usually in adolescence or early adulthood Genetics – Major Depression and Bipolar Disorder more common in first degree relatives
  51. 51. Cyclothymic DisorderSecondary causes of cyclothymic disorder Bipolar Disorder Mood disorders due to a general medical conditionTreatment Initiationof biologic treatment is dependent on the degree of impairment If treatment is indicated, it is similar to that of Bipolar Disorder
  52. 52. Episode Disorder*Major depression episode *Major depression disorder*Major depression episode+ *Bipolar disorder, Type I manic/mixed episode*Manic/mixed episode *Bipolar disorder, Type I*Major depressive episode+ *Bipolar disorder, Type II hypomanic episode*Chronic subsyndromal *Dysthymic Disorder depression*Chronic fluctuations between subsyndromal *Cyclothymic disorder depression & hypomania

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