This ppt will provide a complete information on the topic Depression. It Will also provide the types of depression, pathophysiology involved, causes, drugs used in Depression and its management.

1. 1

2. Points of discussion.
 History
 Introduction & definition
 Different types of depression
 Epidemiology or prevalence of the disease
 Etiology or causes
 Pathophysiology
 Clinical manifestations (Signs and
symptoms)
 Diagnosis and Investigative tests
 Treatment approaches
2

3. History
3
Hippocrates Galen Emil
Kraepelin
Four Humors
or Internal
fluids--Blood
-Black bile
-Yellow bile
-Phlegm
Excess of
black bile-
Melancholic
state
Distinguished
Melancholia into:
-Manic
Depression
-Dementia
Praecox
Melancholic
person
=Depressed

4. 4
Sigmund
Freud
“Mourning and
Melancholia”

5. 5

6. 6
Hamilton Rating scale
for
Depression
Beck Depression
Inventory
Gold Standards

7. Introduction & definition
 According to oxford dictionary- Depression is feeling of
severe despondency, or dejection and the disorder of
mood.
 Leading cause of disability.
 More than 264 million people suffer from depression
worldwide.
 Clinical depression and just feeling sad both are
different.
 Is persistent alteration in one's mood, persistent –ve
mental state more focused on the past.
 Anxiety and depression both are different.
 Anxiety more focused to the future.
 Anxiety= “What if”, “Sense of uncertainty”
 Depression- more focused on the past 7

8. Introduction & definition (continued)
 Can also disturb sleep and appetite. Poor
concentration and tiredness are common.
 Definition(WHO)- A common mental disorder that
presents with depressed mood, loss of interest or
pleasure (anhedonia), feeling of guilt, low self
worth, disturbed sleep or appetite, low energy or
poor concentration.
 Another definition- State of low mood and
aversion(dislike), to activity that can affect a
person’s thoughts, behavior, feelings and sense of
well being.
8

9. Introduction & definition (continued)
 Some very common symptoms include-
S I G E C A P S
S- Sleep Disturbances (Insomnia or Hypersomnia)
I- Interest (reduced) (Anhedonia)
G- Guilt
E- Energy (reduced)
C- Concentration (reduced)
A- Appetite (reduced)
P- Psychomotor retardation (Decreased thinking and
movement)
S- Suicidal thoughts
9

10. Introduction & definition (continued)
 According to psychiatric guidelines- Diagnosis of
depression is mandatory if at least 5 of the
symptoms seen in the individual.
 According to National Institute of Mental Health- It
takes a depressed person, 10 yrs for asking of
help.
 Depression can be : Major(depression for very long
time) and Bipolar
10
Hippocampu
s

11. Different types of depression
1. Major Depressive Disorder (MDD)
2. Treatment Resistant Depression
3. Sub-syndromal Depression (SSD)
4. Persistent Depressive Disorder (PDD)
5. Premenstrual Dysphoric Disorder (PMDD)
6. Bipolar Depression (Manic Depression)
7. Disruptive mood dysregulation disorder (DMDD)
8. Postpartum (or perinatal) depression
9. Seasonal Affective Disorder (SAD)
10. Substance-induced mood disorder
11. Psychotic Depression
12. Depression due to illness
13. Situational Depression (Reactive Depression/Adjustment
Disorder)
14. Atypical and Melancholic Depression
11

12. 1. Major Depressive Disorder
(MDD)
 Very common type of depression.
 Aka- Clinical depression or Unipolar depression.
 According to APA for MDD diagnosis- at least 5
symptoms (S I G E C A P S) persisting for 2 weeks
or more.
 One episode can occur or more often several.
 People show dysphoria, anhedonia, physical
changes(altered weight, appetite, sleep, energy)
 Impaired social life and distress.
12

13. 2. Treatment Resistant Depression
 Those MDD patients who don’t respond to the
treatment.
 One after the other antidepressants are tried but
depression stubbornly hangs on.
 According to some researchers- 4 different
treatments should be tried.
 How to overcome?
- Proper diagnosis
- Counseling on proper dosage and duration
- Switching to different class of the drugs.
- Antipsychotics are also sometimes beneficial
13

14. 3. Sub-syndromal Depression
(SSD)
 Patients do not meet all the criteria of MDD
diagnosis.
 Symptoms similar to clinical depression (MDD)
 DSM-5 (Diagnostic & Statistic Manual of mental
Disorders) classify it in “other specified depressive
disorder”
 At least 3 or 4 symptoms (S I G E C A P S)
persisting for 1 week- patient is sub-syndromally
depressed.
 SSD can worsen to MDD if untreated.
 Treatments include
14
Cognitive
behavioral
therapy
Transcranial
Magnetic
Stimulation

15. 15

16. 16
Transcranial
Magnetic
Stimulation(TMS)

17. 17
TMS working and principle

18. 4. Persistent Depressive Disorder
(PDD)
 Aka- Dysthymia
 Long term form of depression
 Symptoms lasts for 2 yrs or more
 Depressed mood, sadness last for a whole day for
2 yrs or more.
 Children/Teens- irritability symptoms lasts for 1
year
 2 of the symptoms should be there- sleep
problems, poor appetite or overeating, fatigue, low
self esteem or concentration, hopelessness.
 Intensity of symptoms changes time to time
18

19. 5. Premenstrual Dysphoric Disorder
(PMDD)
 10% of childbearing age women experience PMDD
 Hormone based mood disorder.
 Severe form of PMS
 Trigger depression, sadness, anxiety, irritability in
the week before a woman’s period.
 These women are sensitive to change of hormone
levels.
 Estrogen affects dopamine, serotonin,
norepinephrine.
 SSRI before 2 weeks of menstruation start or
during menstruation- found effective.
 Light therapy improves sleep quality and mood.
19

20. 6. Bipolar Depression (Manic
Depression)
 Extreme mood fluctuations.
 Feelings changes from suicidal thoughts to feeling
of euphoria and endless energy.
 Extreme mood swings occur frequently.
 Young adulthood
 Worsen without the treatment.
 Effective treatments- mood stabilizers(Li), light
therapy, talk therapy, atypical antipsychotics (FDA-
approved cariprazine, lurasidone, olanzapine-
fluoxetine combination and quetiapine)
20

21. 7. Disruptive mood dysregulation
disorder (DMDD)
 Screaming and temper tantrums(anger followed by
crying) are typical features
 Diagnosis generally in children
 Struggle with regulating their emotions
 Angry mood, irritable mood most of the day, every
day
 Kids have strong emotional outbursts.
 Unable to contain their emotions.
 Chronic or persistent irritability is common
 DSM-5 classify- children who can not regulate
emotion in age- appropriate way
 Current treatments- Psychotherapy, Parent training
to deal with irritable child
21

22. 8. Postpartum (or perinatal)
depression
 One in 4 women & one in 8 men affected with
postpartum depression
 In women- hormonal shift, fatigue
 In men- environmental, shifting roles, lifestyle
changes with parenting
 “Baby blues”(sad feelings after childbirth)(mild
mood disturbances in new mothers), subsides
within a week or two
 If “Baby blues” condition last for several weeks or
more- Postpartum depression
 According to DSM-5- mood swings, anxiety
symptoms, “baby blues” during pregnancy increase
risk of postpartum depression
22

23. Extreme cases of postpartum
depression
 Two cases recent cases of Kerala (MONDAY,
JANUARY 11, 2021) : Thiruvananthapuram &
Kasaragod
 Kasaragod-
- 23-year-old women arrested- strangled her infant in
earphone wires, killed him, covered him with a
cloth, put infant under her bed.
- Investigating officials- she had a first child,
disappointed that she’s pregnant soon. Experts-
Post partum depression.
 Thiruvananthapuram
- 29-year-old woman arrested- women killed her
infant, buried the body behind her house.
23

24. 9. Seasonal Affective Disorder
(SAD)
 Comes and goes with seasons
 Start- late autumn and early winter
 Ends- Spring and summer
 Increased craving for foods rich in carbohydrates
therefore weight gain
 Patients- overreact, oversleep, withdrawal from
social interaction, feeling of heaviness in legs and
arms
 Women & young children are at higher risk
 Diagnosis- After at least 2 years of recurring
seasonal symptoms
 Possible causes- imbalance of serotonin,
overabundance of melatonin, insufficiency of vit. D
24

25. 10. Substance-induced mood
disorder
 Sedating drugs causes change in mood.
 Substances such as alcohol(too much), opioid
painkillers, benzodiazepines are responsible for
mood changes.
 Depression, loss of interest, anxiety are symptoms
 Sedating drugs causes substance induce mood
disorder.
 Diagnosis- Doctor may rule out the causes of
depression.
25

26. 11. Psychotic Depression
 Severe depression with psychosis.
 Symptoms include hallucinations(to see and to
hear things that aren’t present) & delusions (false
belief of happenings)
 Disturbing fixed false beliefs are present
 Antidepressants + Antipsychotic, electroconvulsive
therapy(ECT)
26

27. 12. Depression due to illness
 Disease such as HIV, cancer, multiple sclerosis,
heart disease can be cause of depression itself.
 Inflammation also plays an important role in
causing depression
Inflammation
Chemicals cross brain, triggering depression
27
Chemicals
released by
immune system

28. 13. Situational Depression
(Reactive Depression/Adjustment
Disorder)
 Short term, stress related type depression.
 Develop after a traumatic event or changes
everyday life
 Examples include- divorce, retirement, loss of a
friend, illness, relationship problems
 Within 90 days of triggering event- situational
depression begins to occur.
28

29. 14. Atypical and Melancholic
Depression
 Are subtypes of Major Depressive Disorder
 Atypical Depression
- Patient eats and sleeps lots
- Seen in young adults
- Emotionally reactive and very anxious
 Melancholic Depression
- Trouble in sleep
- Deeply think over guilt
- Seen more often in older adults
29

30. Epidemiology
 Statistics of India
- Every year 10th of October- celebrated as World
Mental Health Day to spread awareness.
- This year theme- “Mental Health for all due to
Covid-19”
- Causes of depression in covid 19 pandemic-
increased anxiety, fear, isolation, social distancing,
emotional distress.
- Acc. to WHO- Mental Health workforce – not at all
up to the mark in India
- Huge shortage of Psychiatrist and Psychologists
- WHO estimated- 7.5% Indians suffer from mental
disorder. 20% of Indians will suffer by the end of
2020
- India accounts 36.6% of global suicides
30

31.  Statistics of the globe
- More than 264 million people suffer from
depression (WHO 2020)
- 63.8% of adult and 70.77% adolescent- have
severe impairment (NMIH 2017)
- Severe depression among colleges students- rose
from 9.4% to 21.1% (2018)
- 70-80% woman- experience baby blues
- 10-20% woman suffer from PDD
- 2/3rd of those who commit suicide struggle with
depression.
- Suicide is the leading cause for death for 15-19yr
olds
- From 2013-2018- suicide attempts increased from
0.7 to 1.8%
31

32. Etiology or causes
32
 Genetic Causes
- Genes play important role in depression.
- 80 genes linked to depression
- Genetic variation- affects nerve connections in parts of brain, control
decision making.
- Increased variation, increased risk of developing depression.
 Environmental Causes
- Synthetic chemicals, food additives, preservatives, pesticides,
hormones, GM foods, industrial by products
- Nonchemical sources- noise pollution, electrical pollution, natural
disasters, catastrophic events
- Acc. to some researchers- childhood abuse, long term stress at home or
work, coping with loss of loved ones.
- “Sick building syndrome (SBS)”(Being in a building with poor air quality)
- Electrical pollution- EM waves are generated by modern appliances-
thus promotes depression.

33. 33
Majority of genetic
diseases are studied using
this fly

34.  Biochemical Factors
- Traumatic events, blood sugar imbalances, medical
illness- neurotransmitter imbalances
- The Biogenic Monoamine Hypothesis- deficiency of
neurotransmitters (serotonin, NA, DA)
 Endocrine Factors
- Addison’s disease, Acromegaly- brings depressed
mood, anxiety, agitation
- Endocrine- Nervous system work together-
Hypothalamic Pituitary System- homeostatis
- Eg- T3 & T4 hormone produced by thyroid gland
- T3 has major role in mental health
- T3 receptors- more concentrated in the brain
- If thyroid underperforming- T3 &T4 not in enough
quantity
- T3 not gets into the brain, thus increased depression.
- Another eg- Adrenal gland (help regulate internal stress
response. If stress present- adrenal not function
properly), cortisol (uncontrolled stress- cortisol not
produced)
34

35.  Poor nutrition
- Carbohydrates
- Proteins
- Fatty acids
- Vitamin
 Female Sex hormones
 Drugs
35

36. Pathophysiology
1. Biogenic Monoamine Hypothesis
 Serotonin Hypothesis
 Catecholamine Hypothesis
2. Inflammation and depression
3. Connective abnormalities in cortico-limbic
network
36

37. 37
Cortico - Limbic Region

38. 38

39. Clinical manifestations (Signs
and symptoms)
39
NO

40. 40
Symptoms of depression that
goes unnoticed

41. Diagnosis and Investigative
tests
 DSM-5 Diagnostic Criteria for Depression
1. Depressed mood most of the day, nearly every day.
2. Markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every day.
3. Significant weight loss when not dieting or weight gain,
or decrease or increase in appetite nearly every day.
4. A slowing down of thought and a reduction of physical
movement (observable by others, not merely
subjective feelings of restlessness or being slowed
down).
5. Fatigue or loss of energy nearly every day.
6. Feelings of worthlessness or excessive or
inappropriate guilt nearly every day.
7. Diminished ability to think or concentrate, or
indecisiveness, nearly every day.
8. Recurrent thoughts of death, recurrent suicidal
ideation without a specific plan, or a suicide attempt or
a specific plan for committing suicide. 41

42. Investigative tests or Screening
tools
 Hamilton Depression Rating Scale (HDRS)
 Beck Depression Inventory (BDI)
 Patient Health Questionnaire (PHQ)
 Major Depression Inventory (MDI)
 Center for Epidemiologic Studies Depression Scale
(CES-D)
 Zung Self-Rating Depression Scale
 Geriatric Depression Scale (GDS)
42

43. Treatment approaches
43

44. Brief history of development of
antidepressants
 Monoamine oxidase inhibitors
- Isoniazid (Isonicotinyl hydrazide) and Iproniazid
(isopropyl isonicotinyl hydrazide)
Fox and Gibas (1953)
 Tricylic antidepressants
- Imipramine
 Selective Serotonin Reuptake inhibitors
- Fluoxetine (1974) and Nisoxetin (1975)
 Atypical Antidepressants
- Bupropion (1989), Venlafaxine (1993),
Vortioxetine (2013)
44

45. 45
Presynaptic
Neuron
Postsynaptic
Neuron

46. Current Classification
Class A: Monoaminergic modulators
I A : Monoaminooxidase inhibitors (MAOIs)
a: Irreversible non-selective: Tranylcypromine, Phenelzine,
Isocarboxazid
b: Irreversible selective MAO-B inhibitor: Selegiline
c: Reversible selective MAO-A inhibitor: Moclobemide
II A : Neuronal reuptake inhibitors
a: Selective serotonin reuptake inhibitors (SSRIs):
Fluoxetine, Sertraline, Paroxetine, Citalopram, Escitalopram,
Fluvoxamine
b: Serotonin-noradrenaline reuptake inhibitors (SNRI):
Venlafaxine,
Desvenlafaxine, Duloxetine, Milnacipran, Levomilnacipran
c: Noradrenaline and dopamine reuptake inhibitor (NDRI):
46

47. Class III A : Alpha-2 (α2) receptor antagonists
Noradrenergic and specific serotonergic
antidepressant (NaSSA): Mirtazapine
Class IV A : Multimodals
a: Serotonergics: Vortioxetine, Vilazodone,
Trazodone
b: Noradrenergics: Mianserine, Maprotiline
c: Noradrenergic and serotonergics (with significant
muscarinic antagonism): Imipramine, Clorimipramine,
Amitriptiline, Desipramine, Nortriptiline
Class B: Non-Monoaminergic modulators
Melatonine receptors (MT1 and MT2) agonists:
Agomelatine
Class C: Drugs in research and development
47

48.  Mirtrazapine
- Tetracyclic antidepressant
- Alpha 2 adrenergic receptor antagonists
- Thus it increases release of serotonin and NE
- Oral Bioavailability- 50%
- Plasma protein binding- 85%
- Metabolism occurs by CYP1A2, CYP2D6, CYP3A4
- t1/2- 20 to 40 hrs
 Bupropion
- Inhibit NE and DA reuptake
- Unicyclic aminoketone
- Stimulate release of NE and DA from neurons
48

49.  Vortioxetin
- New serotonergic antidepressant
- Mechanism not fully understood
- Believed to bind with high affinity SERT
- Also bind to 5-HT3, 5-HT1A, 5-HT7
- Increase in dose increase causes more binding to
receptor
- Agonist activity at 5-HT 1A
- Partial agonist activity at 5-HT 1B
- Antagonist at 5-HT 1D, 7, 3
- Dose- 10mg/day
- Peak plasma conc. achieved after 7 to 11 hrs
- Bioavailability- 75%
- t1/2- 66 hrs
49

50.  Vilazodone
- Similar action to vortioxetine
- Bioavailability- 72%
- t1/2- 25 hrs
- Plasma protein binding- 96%-99%
 Trazodone
- Inhibit both SERT and Serotonin type 2 receptors
- Inhibit serotonin reuptake, blocks histamine and α-1
adrenergic receptor.
- Evening dose- 75mg to 150mg before bedtime
- Dose increased every 3rd day to about 300mg/day
- For elderly- 100mg/day
50

51.  Mianserin
- Antagonist of serotonin and histamine receptor
- NE reuptake inhibitor
- H1 and α-1 blockade- sedation
- Bioavailability- 20 to 30%
- Plasma protein binding- 95%
- t1/2- 21 to 61hr
 Maprotiline
- Blockade of NE reuptake
- PP binding- 80 to 90%
- Peak plasma conc. Reached after 6hrs
- t1/2- 51 hr
51

52.  Agomelatine
- Melatonergic M1and M2 receptor agonist
- Selective serotonergic 5-HT 2B, 2C receptor
antagonist
- No effect on monoamine uptake
- Agomelatine resynchronizes circadian rhythm
- Antagonism of 5-HT 2C increase NA
and DA in frontal cortex
- Aka as “disinhibitor” of NE-DA
52

53. Most commonly prescribed
antidepressants
1. Amitriptyline
2. Nortriptyline
3. Tianeptine
4. Dothiapine
5. Paroxetine
6. Mirtrazepine
7. Fluoxetine
8. Desvenlafaxine
53

54. Non Pharmacological
Treatments
 Food- Protein rich food (Rajasic foods)
 Hobbies- Those which involve all the 5
senses (e.g.- outdoor games)
 Routines- Walking, pranayamas,
asanas(backward bending asanas),
sufficient sleep (around 10 pm)
 Motivate to think positively, write down 10
+ve points before going to bed which made
you happy during the whole day.
54

55. References
1. Joseph H. Porter, Todd M. Hillhouse, A brief
history of the development of antidepressant
drugs: From monoamines to glutamate
2. Sebastian A. Alvano, Luis M. Zieherb, An updated
classification of antidepressants: A proposal to
simplify treatment
3. Bianca Nogrady, Antidepressant Approvals Could
Herald New Era in Psychiatric Drugs
4. Etiology of Depression: Genetic and
Environmental Factors Radu V. Saveanu, MD,
Charles B. Nemeroff, MD, PhD
5. The Etiology of Depression - Depression in
Parents, Parenting, and Children - NCBI
Bookshelf
55

56. 6. The diagnosis of depression: current and emerging
methods, Katie M. Smitha, Perry F. Renshawb, and
John Bilelloa
7. Pathophysiology of depression and mechanisms of
treatment, Brigitta Bondy
8. The emergence of new antidepressants for clinical
use: Agomelatine paradox versus other novel agents
Olumuyiwa John Fasipe
9. https://emedicine.medscape.com/article/286759-
print
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