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1. DEPRESS
ION
 Dr. Saqib Siddique, Assistant
Professor of Psychiatry
 MBBS (KMC), DCP (IRE), FCPS
(PAK), Certified Cognitive Therapist
(KMU).

2. TERMS
USED
 Depression
 Depressive disorder
 Depressive illness
 Depressive Episodes( mild, mod, severe)
 Major Depressive Disorder

3.  The individual usually suffers from depressed mood, loss of interest and
enjoyment, and reduced energy: for most of the times for 2 wks. If severe
enough, the 2 wks duration is not mandatory.
 Three types. Mild, Moderate and Severe.

4. OTHER
SYMPTOMS
INCLUDE
a) Reduced concentration and attention;
b) Reduced self-esteem and self-confidence;
c) Ideas of guilt and unworthiness (even in a
mild type of episode);
d) Bleak and pessimistic views of the future;
e) Ideas or acts of self-harm or suicide;
f) Disturbed sleep
g) Diminished appetite.

5. EPIDEMIOL
OGY
The 12-month prevalence of major depression in the
community is around 2--5% .
The lifetime risk is 10–20%.
The mean age of onset is about 27 years
M:F------1:2
Rates of depression are higher in the unemployed.

6. CORE
SYMPTO
MS
 Low mood
 Loss of Interest in daily activities
 Fatigability

7.  Disturbed Sleep
 Disturbed Appetite
 Sexual Function/Menstrual disturbances

8.  Concentration
 Memory

9. DEPRESSIVE COGNITIONS
 Guilt
 Worthlessness
 Hopelessness
 Helplessness

10. RED FLAG
SYMPTOMS
 Death wishes
 Suicidal ideas
 Suicidal plans

11. PSYCHOT
IC
FEATURE
S
 Delusions
 Hallucinations

12.  Bipolar Depression
 Mixed Affective State
 Physical Illness
 Drugs
 Reaction to Stressful life event

13. Anxiety Disorders Substance misuse

14. AETIOLOG
Y
 Multifactorial

15.  Polygenic inheritance
 Heritability Estimates of 37% ( Bienvenu et al 2011)
 Lifetime risk of first-degree relatives is 20-30%

16.  Neuroticism
 Sociotropy
 Poor coping skills

17. EARLY
ENVIRONMEN
T
 Family Discord and lack of adequate care
 Physical and sexual abuse
 Non-caring and overprotective parenting
style
 Mother with post-natal depression

18.  Entrapment and humiliation

19. HOLMES
AND RAHE
STRESSOR
SCALE
 Also known as Social Readjustment Rating
Scale
 43 Major Life events
 Past 1 year or expected in near future.
 Multiply number by frequency

20. SOCIAL
READJUSTME
NT RATING
SCALE
 Based on this analysis, Holmes and Rahe
(1967) developed the (SRRS) to measure life
change as a form of stress. The scale assigns
numerical values to 43 major life events.
These values are supposed to reflect the
magnitude of the readjustment required by
each change (see Table 13.1). In using the
scale, respondents are asked to indicate how
often they experienced any of these 43
events during a certain time period
(typically, thepast year). The numbers
associated with each event checked are then
added. This total is an index of the amount
of change-related stress the person has re-
cently experienced.

21.  Lack of social support

22. PHYSICA
L
CONDITI
ONS
 Hypothyroidism
 Hyperparathyroidism
 Cushing Disease
 Malignancies
 HIV

23. MEDICA
TIONS
AND
SUBSTA
NCES
 Alcohol and Drugs
 Beta Blockers
 Methyldopa
 Phenytoin, Levetiracetam
 Benzodiazepines

24. MONOAMINE
THEORY

25. PSYCHOLO
GICAL
THEORIES
Psychodynamic
theories
Cognitive
theories

26. Negative
Views
World
•Everyone
is against
me
Future
•I will never
get out of
this
Self
•I am
worthless

27. CBT
Model
Thoughts
Behaviors
Physical
manifestations
Feelings

28. Thoughts
No one likes me
I always mess up
Behaviors
Withdraw from
social life
Stop doing things
Physical
manifestations
Tense
Aches and pains
Feelings
Sad
anxious

29. DETECTION
 Use two screening questions.
 During the past month, have you been
feeling down, depressed or hopeless?
 During the last month, have you often been
bothered by having little interest or
pleasure in doing things

30. TOOLS TO
HELP
ESTABLISH
SEVERITY OF
THE
CONDITION
 Personal Health Questionare-9 (PHQ-9). 9
item Reliable Screening tool in Primary
Care.
 Beck Depression Inventory (BDI). (Self
Rating Scale- Educated Patients)
 Hamilton Depression Rating Scale (HAM-
D). (Clinician Rating Scale). Reliable in good
clinical hands.
 Beck Scale for Suicide Risk.

31. COURSE AND
PROGNOSIS
 Average length of a depressive episode is
about 6 months.
 80% recurrence
 Best predictor is history of previous episodes

32. POOR
PROGNOSTIC
FACTORS
 Early onset
 Poor social support
 Poor physical health
 Comorbid personality disorder
 Comorbid substance misuse

34. MILD
DEPRESSION
(NICE
GUIDELINES)
 Short lived----Watchful waiting
 Antidepressants not recommended as first
line for mild depression
 Persistent mild depression----Exercise
program
 Sleep Hygiene
 Self Help books on Cognitive behavior
therapy

35. NICE
GUIDELINES
 Moderate or Severe Depression
 Combination of medications and
Psychotherapy

36. ANTIDEPRESSA
NTS
 Suggest SSRI as first choice (NICE and Maudsley
Guidelines)
 Starts to work in 1-2 weeks…..Change in treatment if no
response at all at 3-4 weeks.
 If effective…..Continue for 6-9 months.
 Warn about discontinuation symptoms.

37. PSYCHOT
HERAPY
 Cognitive Behavior Therapy
 Interpersonal Therapy
 Couple Therapy

38. COGNITIVE
BEHAVIORAL
THERAPY
 Dysfunctional thoughts are found and
challenged and changed into realistic ones.
 Behavioral techniques are used to change
behavior.
 6-12 sessions with each session 45min to 1
hour.
 Clear agenda with homework and
behavioral experiments.

39. INFORMATIO
N CARE
 Provide appropriate information on nature
of illness. Educate about treatment
(including late onset of therapeutic action
and side effects. Discuss fear about
addiction to antidepressants). Avoid use of
clinical language & provide information in
language understood by the patient.
 Support and Reassurance. As the patient
may feel being hopeless and helpless.
 Ensure follow up. Engage family when
needed.
 Always ask directly about suicidal ideas &
intent. Advise patients & carers to be
vigilant in high risk cases.

40. FACTS ABOUT
ANTIDEPRESSA
NTS
 In general practice, they all have almost
equal efficacy.
 SSRIs and SNRIs better tolerated than
TCAs.
 TCAs more toxic in overdose.
They have very different costs!
Sertraline in Pregnancy and Paroxetine in
Lactation among the recommended SSRIs.

41. THE END