2. Depression is a common disorder that
affects about 15% of the population at
some time in their lives.
It is characterized by a pervasive and
persistent lowering of mood, sleep
disturbance, lowering of appetite and
weight loss;
It is not the same as unhappiness;
It is twice as common in females than in
males.
overview
3. Mania: the central features are over-
activity,mood change,and self-important
ideas. The mood change may be
towards elation or towards irritability.
Mania is less widely encountered than
depressed mood.
overview
6. Depressive syndromes
The central features: low mood, lack of
enjoyment, pessimistic thinking, and
reduced energy, -----all lead to
decreased functioning.
Appearance: dress and grooming
neglected; turning downwards of the
corners of the mouth and by vertical
furrowing of the corners of the brow.
7. Pessimistic thoughts:( depressive
cognitions)
—concerned with the present: see him as
a failure, loss self-confidence, unhappy in
everything
—concerned with the future:expects the
worst, foresees failure in work, finance,
family,health. Hopelessness, uselessness,
helplessness.
Depressive syndromes
8. —concerns with the past: unreasonable
guilt and self-blame about minor
matters.Feeling guilty about past trivial
acts of dishonesty or letting someone
down.Other memories are focused on
unhappy events.
Lack of interest and enjoyment
Reduced energy
Depressive syndromes
9. Psychomotor retardation: walks and acts
slowly, slowing of thought, speaks
slowly,delay or pause in conversation.
Anxiety:is common in some less severe
depression. Irritability, agitation.
Biological symptoms: sleep disturbance,
diurnal (昼夜)variation of mood, loss of
appetite, loss of weight, constipation, loss
of libido,and among female, amenorrhoea
（闭经）.
Depressive syndromes
10. Physical symptoms: complaints of
constipation, fatigue, and aching
discomfort anywhere in the body.
Other psychiatric symptoms:
depersonalization, obsessional symptoms,
phobia, and disassociative symptoms
such as fugue or loss of function of a limb.
Poor memory, pseudodemantia.
Depressive syndromes
11. Severe depressive
disorders
Also called psychotic depression.
Delusion: mood congruent delusion.The
themes are worthlessness, guilt, ill-
health, poverty.
delusion of guilt
delusion of impoverishment
hypochondriacal delusion
persecutory delusion
13. Mania
Central features: elevation of mood,
increased activity, and self-important
ideas.
Mood: cheerful and optimistic, euphoria
欣快.Other patients may be irritability or
angry.
Appearance: Clothes may be brightly
colored and ill-assorted.
14. Over-activity: patients start many activities but
leave them unfinished as new ones catch
their fancy.Their speech is often rapid and
copious （rich）as thoughts crowd into their
minds in quick succession. Flight of ideas
with such rapid changes that it is difficult to
follow the train of thought.Appetite increased,
sleep reduced, sexual desires increased.
Mania
15. Expansive ideas: patients believe that
their ideas are original, their opinions
important, and their work of outstanding
quality. Many patients become
extravagant, spending more than them
can afford on expensive cars or jewellery.
Grandiose delusion:some patients may
believe they are religious prophets预知 or
destined to advise statesmen about great
issues.
Mania
16. Delusions of persecution: patients believe
that people are conspiring against them
because of their special importance.
Delusion of reference ,passive feelings.
Hallucination: usually consistent with the
mood.Auditory or visual hallucination.
Insight: impaired.
Mania
17. Bipolar affective disorder has a lifetime
prevalence of about 0.5%. It is characterized
by discrete(不连续) episodes of depression and
mania, between which the person usually
returns to normal. It usually begins in the
early twenties and there is evidence of a
strong genetic component. Treatment
usually consists of prophylactic treatment
with lithium carbonate and specific
treatment of the manic or depressive phases.
Clinical feature
18. Depression is common in primary care
and the general hospital. It often goes
unrecognized. It is not difficult to recognize but
can present disguised as physical symptoms or
problems with fatigue or memory, as shown in
Box 1.
1 Depression
19. Box 1
Traps for the unwary: how
depression can present in disguise
in primary care
Headache: ‘tension headache', which is
bilateral, frontal, band-like
Other pain disorders:
-- atypical chest pain
-- low back pain
--atypical facial pain
Fatigue
Weight loss
Poor memory
21. Classifications based on
aetiology and symptoms
Reactive and endogenous （内源 ）depressive
Neurotic and psychotic depressive
Melancholic忧郁 and somatic depressive
Primary and secondary depressive
22. Classifications based by
course and time of time
Unipolar and bipolar disorders
Seasonal affective disorder
Involutional（复发） depression
Senile（老年） depression
24. Classification of bipolar disorder
ICD-10 DSM-IV
Manic episode Hypomanic episode
Hypomania Manic episode
Mania Mild
Mania with psychosis Moderate
Severe
Severe with psychosis
Bipolar affective disorder Bipolar I and bipolar
II disorder
Currently hypomanic Current
Currently mania hypomanic
Currently depressed manic
Currently mixed depressed
In remission mixed
Cyclothymia
25. Classification of depressive disorders
ICD-10 DSM-IV
Depressive episode Major depressive episode
Mild Mild
Moderate Moderate
Severe Severe
Severe with psychosis Severe with psychosis
Other depressive episodes
Atypical depression
Recurrent depressive disorders Major depression disorder
recurrent
Currently mild
Currently moderate
Currently severe
Currently severe with psychosis
In remission
Persistent mood disorders Dysthymic disorder
Cyclothymia
Dysthymia
Other mood disorders Depression disorders not otherwise
26. Clinically significant depression is called
depressive illness or major depression.
Major depression used to be called
‘endogenous‘ and milder ( or minor) depression
used to be called ‘ reactive' depression, with the
assumption that it was secondary to life
stresses. In fact, life events are important in all
forms of depression.
Epidemiology
27. The prevalence of major depression in
community surveys in the UK is about 4% in
men and 8% in women. The lifetime risk, or
the proportion of people who will suffer one
or more episodes of major depression at
some time in their life, is about 15%. Rates
increase with age and are higher in urban
areas. Suicide rates in major depression are
about 10% over the long term.
28. The aetiology of mood disorders
Genetic causes
Family history of depression
Early development
Parental discord （不和）in childhood
Childhood abuse
Relationships with parents
Personality
Neuroticism神经质
Environmental factors
Recent stressful life events
Lack of social support
29. Depression pathogenesis. Schematic representation of the ongoing interactions between biological
risk factors, exogenous environmental stressors and critical limbic-cortical circuits responsible
for maintaining normal responses to ongoing emotionally salient stimuli. Decompensation of this
system precipitated by unknown factors leads to a disequilibrium state otherwise know as a major
depressive disorder. Adapted & modified from Akiskal & Mckinney (1973).
A Model of Depression Pathogenesis
30. Depression: Clinical dimensions. DSM-IV diagnostic criteria are reorganized into four principal
behavioral domains – mood, cognitive, circadian, and motor – of relevance to a putative neural
systems model of the depression syndrome.
Primary Clinical Dimensions of Major Depressive Disorders
31. Predisposing causes
There is a genetic predisposition to major
depression, as shown by increased
rates in first-degree relatives and higher
concordance rates in monozygotic
compared with dizygotic twins.
32. Social and environmental
predisposing factors include:
historical factors: early maternal death,
parental neglect, a long period of
separation from a parent during childhood,
childhood sexual abuse.
current factors: unemployment, lack of
a confiding relationship.
34. The symptoms of depression can be
remembered as falling into three main
groups:
1 mood and motivation, biological and
cognitive (Box 2).
Symptoms of depression
How to ask about important
symptoms at interview is
shown in Table 6.
35. Mood and motivation symptoms
Persistently lowered mood (may be worse
Diminished interest or pleasure in almost
Social withdrawal
Loss of energy
Poor concentration
Biological symptoms
Significant weight loss when not dieting
Sleep disturbance most days (either initial insomnia or
early morning waking)
Retardation or agitation
Decreased sex drive
Cognitive changes
Depressive ideation: feelings of guilt, worthlessness
self-blame
Suicidal thoughts
Hopelessness
all activities
in the morning)
36. Feelings of sadness, often with increased
tearfulness. The person often feels they are
unable to cheer up and enjoy things they
once did, such as being with friends or
watching TV; this loss of pleasure is called
anhedonia快感缺乏.
Loss of interest in family, friends and hobbies
occurs, with social withdrawal.
People often describe increased irritability and
snappiness（骂人） at home.
Mood and motivation
symptoms
37. for everyday recent events. Anxiety
symptoms, worrying and panic attacks
can occur in depression.
The person reports low energy and also
poor concentration, which can result in
absent mindedness and forgetfulness
38. Cognitive symptoms
Low mood leads to a deterioration in how
people come to think about themselves.
This involves inappropriately negative
thoughts about the past (guilt,regrets and
self- blame), about the present (low self-
esteem, worthlessness) and about the
future (pessimism, hopelessness,
thoughts of dying and suicidal ideas).
39. Biological symptoms
Biological symptoms (also called
vegetative symptoms) are markers of
moderately severe depression and are
less evident in milder depressive states.
Very severe depression, the following
features can appear.
40. Loss of appetite and weight
Loss of sex drive
Early morning waking: this characteristic symptom
involves waking in the early hours of the morning
often 4 Or 5 a.m. and being unable to get back to
sleep.
Diurnal variation of mood, such that mood is worse
in the morning and slowly lifts in the evening.
Non-specific physical symptoms :such as tension
headache, back pain and atypical chest can also
occur.
41. Sleep
Appetite
Weight
Libido
Daily variation
in mood
biological features in depression
Difficulty getting to sleep
(initial insomnia)
Unchanged or increased
Unchanged or increased
Unchanged or reduced
Worse in the evening
Mild depression moderate-to-severe
depression
Early morning waking
Decreased
Loss
Reduced
Worse in the
morning(diurnal mood
variation)
42.
43. Psychomotor retardation: the person is aware
of thinking slowly, and at interview their
speech and movements are perceptibly
slowed up. In the most severe cases, the
patient stops speaking (becomes mute（哑的）)
and becomes immobile (a depressive 'stupor').
44. Very severe depression, the following features
can appear : so-called psychotic depression.
These will have a depressive content to them
and can be thought of as extreme versions of the
negative cognitions. Delusions can be
persecutory, hypochondriacal (the person
believes they have cancer), nihilistic (the person
believes the world is about to end) or of guilt (the
person believes they are to be blamed for
dreadful events). Auditory hallucinations can be
of voices insulting the person or saying he/she is
evil.
45. Management of depression
History-taking will include alcohol and drug use
and psychosocial history with evidence for
supportive relationships. Suicidal risk
assessment is important .
46. Physical investigations will include eosinophil
sedimentation rate(ESR) and thyroid （甲状腺）
function and, in older patients, chest X ray
and computed tomographic (CT) scan.
Major depression is usually treated with
antidepressant drugs;these will be effective in
70%. Cognitive behavior
therapy,interpersonal therapy and
psychodynamic interpersonal therapy are
also used, if available.
47. Psychosocial interventions will be
important to relieve ongoing stresses of
relationship difficulties, financial problems
or housing difficulties. In severe
depression, antidepressants are superior
to psychological treatments and should
always be considered as the first-line
treatment.
48. If there is no response to first-line treatment
with full dosage antidepressant for 6 weeks,
the next step is to change to another class of
antidepressant drug, after checking
compliance. Maintaining factors such as
underlying organic illness or continuing
psychosocial stresses must be checked.
Adding lithium to antidepressant drug
treatment will be effective in some patients.
49. For severe depression or high suicidal risk,
inpatient admission may be needed. Psychotic
depression will also need antipsychotic drug
treatment, with ECT (electroconvulsive therapy)
if no improvement is made.
50. Special types of depression
Bereavement :A normal grief reaction
following the death of a close relative or
spouse lasts up to 6 months. There are
usually three stages.
51. 1. Shock, with a feeling of numbness and
unreality,usually lasting a few days
2. Sadness, with tearfulness and loss of
sleep and appetite, sometimes along
with anger or guilt at not having been
able to do more. Illusions or fleeting
hallucinations of hearing or seeing the
deceased person around the house can
occur and are normal.
3. Acceptance.
52. Bereavement reactions can be abnormal,
for instance if they continue for longer than
6 months, are especially severe or have
unusual symptoms. Abnormal bereave-
ment reactions are more likely if the death
was unexpected, if the relationship with the
deceased was itself abnormal or if the
normal grieving process is interrupted.
53. Management of abnormal bereavement
may involve use of antidepressant
drugs or cognitive behavior therapy.
54. Seasonal affective disorder
Seasonal affective disorder (SAD) is an
uncommon subtype of major depression
where episodes occur as daylength shortens.
Melatonin appears to be involved.
Exposure to bright artificial light
(phototherapy（光疗 ）) has been shown to be an
effective treatment.
55. Bipolar affective disorder
You should:
~ know the definition, epidemiology and
causes of bipolar disorder
~ know the symptoms of mania
~ know about the management of acute mania
~ know about the long-term management of
bipolar disorder
56. Bipolar affective disorder used to be called
manic depressive psychosis. It is a disorder
characterized by episodes of major
depression and, at other times, mania, where
mood is abnormally elated. The terms mania
and hypomania mean the same.
57. In some cases, there will never be a
depressive episode and the disorder will
be recurrent episodes of mania; this is
still called bipolar disorder.Between
episodes, the person returns to their
normal self,usually with good insight
into the previous episode. After a first
manic episode, the risk of recurrence is
about 70%.
58. Epidemiology
Bipolar affective disorder has a lifetime
prevalence of about 0.5%, with men and
women equally affected.Mean age at first
onset is in the twenties, although the first
episode is occasionally in late life. In some
people,the disorder is preceded by long-
standing mild mood swings, called
cyclothymic disorder.
59. Causes
Predisposing causes
Bipolar disorder has a strong genetic
component. A family history of bipolar disorder
and major depression is common. The
concordance rate in monozygotic twins is
approximately 50% and it rises to 80% if major
depression in the co-twin is counted as well as
bipolar disorder.
60. Precipitating causes
Stressful life events are important in
triggering both manic and depressive
episodes. Childbirth can be a precipitant.
Street drug use, including cannabis, is often
a precipitant of manic episodes. Sometimes
a first manic episode can be triggered by
antidepressant drug treatment or the use of
drugs such as steroids（类固醇激素）.
62. The symptoms may come on after a
stressful event or street drug use. Usually,
there will be history of increasingly elated
mood for a few days or weeks, sometimes
with irritability. The person will be more and
more talkative and energetic, needing less
and less sleep.They will often develop
grandiose plans and spend increasing
amounts of money. They can become
sexually disinhibited.
63. Symptoms of mania grouped according to
the categories of the mental state
examination
Category Appearance
Behaviour Speech
Mood Thoughts
Abnormal experiences Abnormal beliefs
Cognitive state Self-appraisal
64. Symptoms
May be dishevelled（蓬乱）, unshaven; clothes
and make-up may be bright and bizarre .
Often restless and overactive; socially
disinhibited, with overfamiliarity.
Pressure of speech: increased rate and
difficult to interrupt; may develop flight of
ideas, with non-stop ideas connected by puns
and rhymes ('clangs')
65. Elated and grandiose; often irritable
Describes pressure of thought, with
accelerated thinking
Auditory hallucinations can occur, with
grandiose themes
Delusions can occur, either persecutory
or grandiose, of grandiose identity (e.g.
being royalty) or ability (e.g. having
supernatural powers)
66. Normal, although may show impaired
attention span with distractibility
Insight is usually lost in acute mania
67. Management
A detailed history is required, including
family history and drug history. It is
sometimes impossible to take a full history
from someone with mania, and an account
by an informant who knows the patient is
important . Acute mania often needs
inpatient admission because of the
behavioral disturbance.
68. The patient may be at risk of harming
himself/herself (e.g: may try to jump off a
building because of delusions of being able to
fly) or of being exploited or harmed by others
(may be mugged,or persuaded to engage in
sexual activity which, when well, would be
abhorrent to the person). Lack of insight may
necessitate formal admission under the Mental
Health Act. Physical investigations will include
thyroid function to exclude hyperthyroidism.
69. Drug treatment initially will usually involve
antipsychotic drugs, with a short-acting
benzodiazepine for sedation if needed. After
remission, management continues using the
Care Programme Approach, with a named
care coordinator to organize the care
package.
70. Unlike schizophrenia, remission is usually
complete and the care package may be
fairly simple and short lived. The person
can be expected to return to work.
Long-term lithium treatment should be
considered if the person has had two or
more manic episodes.
71. Case analysis
Peter is a married 48-year-old teacher. He
had an episode of depression when 25
years of age. He presents now to his GP
with a 3-month history of Iow mood and
energy, tearfulness, headaches, early
morning waking and weight loss of 5 kg.
72. Mary is a 45-year-old married woman who
works in a local supermarket. She has two
daughters, who are in their twenties and have
recently left home. Her husband died
suddenly of a heart attack 18 months ago, at
the age of 53. She lost her own mother when
she was 9 years old, through breast cancer,
and her father was killed in a road traffic
accident when she was 23.
73. She has felt desperately unhappy since her
husband's death and has found it difficult to
cope. She has lost 2 stones in weight and has
been unable to go into work for the last 2
months because she feels so tired. She does
not socialize and has lost touch with many of
her friends. She spends her evenings looking at
pictures of her dead husband. She feels Iow all
the time, and his death seems as painful to her
now as it was when it happened 18 months ago.
She does not sleep well and feels anxious most
of the time.
