Understanding
Depression
Madan Baral
Second Semester, B. Pharmacy
School of Health and Allied Sciences
Pokhara University,...
Objectives
•Understand Signs and Symptoms
•Differentiate between types of depression
•Understand Causation
•Understand Dia...
WHAT IS DEPRESSION ?
•common potentially debilitating
psychiatric disorder characterized
by depressed mood, loss of
intere...
HISTORY
•Ancient Egyptians wrote about depression more than 3000
years ago
•Ancient Greek thought depression as the cause ...
CLASSIFICATION ON THE BASIS DSM-IV
• Depression classified with its subtypes under Mood Disorder by American
Psychiatric A...
Facts and Statistics
•People of all ages, backgrounds, lifestyles, and nationalities
suffer from major depression, with a ...
Major Depressive Disorder
•Also called clinical depression or unipolar depression
•The most prevalent depressive disorder
...
Symptoms
•The symptoms of depression are:
Emotional Symptoms: Physical Symptoms:
Depressed mood Change in body weight and ...
Types
•Classified further on the basis of occurrence
a. Single Episode
b. Recurrent
•Single episode - occurs only once and...
Dysthymia
• chronic “low-grade” or mild depression
• symptoms not as strong as the symptoms of major depression
• Diagnost...
Bipolar Disorder
•manic-depressive disorder
•presence of one or more episodes of abnormally elevated
energy levels, cognit...
Etiology and Pathophysiology
A.Biological Theories
1.Genetics
2.Biochemical Theories
a. Monoamine Hypothesis
b. Neurotrans...
Genetics
Family Studies
• first degree relatives of (children,siblings,parents) of
depressed individuals are 1.5 to 3 time...
Biochemical Theories
• Monoamine Hypothesis
• Neurotransmitter Dysregulation Hypothesis
• Neuroendocrine Findings
Monoamine Hypothesis
• Depletion in the levels of serotonin, norepinephrine, and/or
dopamine in the CNS.
• Norepinephrine ...
Monoamine Hypothesis
Limitations
• Delayed onset of drug
• Not all the depressed patient have decreased synaptic
concentra...
Neurotransmitter Dysregulation Hypothesis
•Explains depression as the cause of failure of regulation of
neurotransmission ...
Neuroendocrine Findings
•Neuroendocrine abnormalities may develop depression
•Abnormal thyroid function test including low...
Psychological Theories
• Psychoanalytical Theory
• Learning Theories
• Object Loss theory
• Cognitive Theory
Psychoanalytical Theory
•Sigmund Freud features of melancholia
– a profoundly painful dejection
– loss of interest in worl...
Learning Theory
•Seligman’s “learned helplessness” experiment on dogs
•Helplessness in human with numerous traumatic situa...
Object Loss Theory (Attachment Theory)
•Attachment theory by John Bowlby, English psychiatrist,
•Relationship between depr...
Cognitive Theory
• Put-forth by Aaron Beck
•3 cognitive distortion reality
•Negative expectation
– Environment
– Self
– Fu...
Social Theory
•Family
–Problems with family
–Family stress
•Social
–Substantial life events
–Social isolation
Diagnosis
•Clinical Assessment
•Behavioral Rating Scales
•DSM-IV Criteria and IDS-10 Criteria
Clinical Assessment
•By Clinician,trained medical practitioner, psychiatrist or
psychologist
•Mental state assessment
– ap...
Behavioral Rating Scales
•Set of questionnaire for depression assessment
•Uses
– Screening mental state
– Quantifying targ...
DSM-IV Criteria and ICD-10 Criteria
•DSM-IV
– American Psychiatric Association's revised fourth edition
of the Diagnostic ...
Treatment
•Non-Drug Therapy
–Psychotherapy
–Phototherapy
–Electroconvulsive Therapy
•Pharmacotherapy
Psychotherapy
•Interpersonal therapy:
–assist in solving relationship
problems that cause depression
•Cognitive-behavioral...
Electroconvulsive Therapy
How is it done?
•Pulses of electricity are sent through the
brain via two electrodes
•Painless p...
Pharmacotherapy
• Use of antidepressants
• Selective serotonin-reuptake inhibitors
(SSRIs) like fluoxetine, paroxetine,
se...
References
• Young Kimble (2000) et al., Applied Therapeutics: The Clinical Use of Drugs
(7th Ed.), Lipincott Williams & W...
THANK YOU
Understanding depresssion
Understanding depresssion
Understanding depresssion
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Understanding depresssion

  1. 1. Understanding Depression Madan Baral Second Semester, B. Pharmacy School of Health and Allied Sciences Pokhara University, Dhungepatan, Lekhnath-12, Kaski , Nepal
  2. 2. Objectives •Understand Signs and Symptoms •Differentiate between types of depression •Understand Causation •Understand Diagnosis Methods •Understand Treatment
  3. 3. WHAT IS DEPRESSION ? •common potentially debilitating psychiatric disorder characterized by depressed mood, loss of interest or pleasure, feelings of guilt, disturbed sleep or appetite, low and poor concentration.
  4. 4. HISTORY •Ancient Egyptians wrote about depression more than 3000 years ago •Ancient Greek thought depression as the cause of excess of bile •Hippocrates, first person to throughly describe the condition as a somatic illness and coin the term “melancholia” •Ludwig Van Beethoven, Charles Dickens, Winston Churchill, Abraham Lincoln and Ernest Hemingway some famous people said to have suffered from depression
  5. 5. CLASSIFICATION ON THE BASIS DSM-IV • Depression classified with its subtypes under Mood Disorder by American Psychiatric Association published in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) ✦ Mood Disorder A. Depressive Disorder 1. Major Depressive Disorder, Single Episode 2. Major Depressive Disorder, Recurrent 3. Dysthymia Disorder 4. Depressive Disorder Not Otherwise Mentioned – Bipolar Disorder » Bipolar Disorder, Single Episode » Bipolar Disorder, Recurrent A.Cyclothymic Disorder 1. Bipolar Disorder Not Otherwise Specified 1. Secondary Mood Disorder due to Non-psychiatric Medical Condition 2. Substance- Induced Mood Disorder 3.Mood Disorder Not Otherwise Specified
  6. 6. Facts and Statistics •People of all ages, backgrounds, lifestyles, and nationalities suffer from major depression, with a few exceptions. •Up to 20% of people experience symptoms of depression. •The average age of first onset of major depression is 25-29 •Ranked as 4th highest public concern according to WHO and assumed to be 2nd by 2020
  7. 7. Major Depressive Disorder •Also called clinical depression or unipolar depression •The most prevalent depressive disorder •Some 340 million persons worldwide meet the criteria for clinical depression
  8. 8. Symptoms •The symptoms of depression are: Emotional Symptoms: Physical Symptoms: Depressed mood Change in body weight and appetite Loss of interest or pleasure Disturbances of sleep and other Circadian rhythm Anxiety Fatigue Diminished ability to think or concentrate, or indecisiveness Psychomotor agitation or retardation Feeling of excessive or inappropriate guilt Unexplained body aches Recurrent thoughts of deaths and suicidal Headache
  9. 9. Types •Classified further on the basis of occurrence a. Single Episode b. Recurrent •Single episode - occurs only once and meets all the diagnostic symptoms of major depression •If untreated, 85% of persons who have one episode of depression will have another episode within 10 years •Recurrent-2 major depression episodes, separated by at least a 2 month period •Median number of depressive episodes per person is 4 •25% have 6 or more episodes
  10. 10. Dysthymia • chronic “low-grade” or mild depression • symptoms not as strong as the symptoms of major depression • Diagnostic Symptoms : A. Depressed/irritable mood B. Presence of two of the following: • Appetite disturbance • Sleep disturbance • Low energy/fatigue • Poor concentration of difficulties making decision • Feelings of hopelessness C. Present for two year period (one year in children and adolescents)
  11. 11. Bipolar Disorder •manic-depressive disorder •presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or more depressive episodes Characteristic Episodes – Depressive Episode :disturbances in sleep and appetite, fatigue, –Manic Episode : elevated, irritable mood state ,grandiosity –Hypomanic Episode : milder mania
  12. 12. Etiology and Pathophysiology A.Biological Theories 1.Genetics 2.Biochemical Theories a. Monoamine Hypothesis b. Neurotransmitter Dysregulation Hypothesis c. Neuroendocrine Findings B.Psychological Theories 1. Psychoanalytical Factors A. Learning Theories 1. Object Loss theory 2. Cognitive Theory a. Social Theory a.Family Based c.Society Based
  13. 13. Genetics Family Studies • first degree relatives of (children,siblings,parents) of depressed individuals are 1.5 to 3 times more likely to have depression compared to general population Twin Studies •concordance rate of monozygotic twins ranges from 54-65% while in dizygotic twins in only 15-24
  14. 14. Biochemical Theories • Monoamine Hypothesis • Neurotransmitter Dysregulation Hypothesis • Neuroendocrine Findings
  15. 15. Monoamine Hypothesis • Depletion in the levels of serotonin, norepinephrine, and/or dopamine in the CNS. • Norepinephrine regarded as the component in the mobilization of the body toy deal with stressful event. • Serotonin System- mood and arousal thinking,energy, libido, cognition,appetite,aggression and circadian rhythm. • Dopamine System -human mood and behavior. • Decreased level of biogenic amines in synaptic cleft inhibits the transmission of impulses from one neuron to another causing a failure of the cells to fire or charge. • Pathophysiology supported by the mechanism of action of antidepressants and autopsy of depressed person
  16. 16. Monoamine Hypothesis Limitations • Delayed onset of drug • Not all the depressed patient have decreased synaptic concentration of of biogenic amines • antidepressant can work via other mechanisms which do not involve reactive increased in synaptic neuro-transmitter concentration (eg. can block corticotropin releasing factor)
  17. 17. Neurotransmitter Dysregulation Hypothesis •Explains depression as the cause of failure of regulation of neurotransmission system Factors - Impairment in homeostasis or regulation - Disruption of normal periodicity ( Circadian rhythm ) - less selective response to stimuli
  18. 18. Neuroendocrine Findings •Neuroendocrine abnormalities may develop depression •Abnormal thyroid function test including low triiodothronine(T3) and thyroxine(T4) •Abnormal response to TRH(thyroid releasing hormone) consisting or blunted or exaggerated thyroid stimulating hormone (TSH) •Clinical hypoparathyroidism •HPA axis influence manifestation of depression •Concentrations of CRF is elevated during depressive episodes •Decreased hippocampus
  19. 19. Psychological Theories • Psychoanalytical Theory • Learning Theories • Object Loss theory • Cognitive Theory
  20. 20. Psychoanalytical Theory •Sigmund Freud features of melancholia – a profoundly painful dejection – loss of interest in world – loss of capacity to love •Interpretation of melancholia – actual loss of loved one or emotional rejection –feelings of self-hatred develop and worthlessness and losses his or her self-esteem
  21. 21. Learning Theory •Seligman’s “learned helplessness” experiment on dogs •Helplessness in human with numerous traumatic situations either real or perceived •Seligman’s interpretation of depression –Learned helplessness predisposes depression by imposing a feeling of lack of control and hopelessness over their life situation and failures
  22. 22. Object Loss Theory (Attachment Theory) •Attachment theory by John Bowlby, English psychiatrist, •Relationship between depressive disorder in adulthood and the quality of the earlier bond between the infant and their adult caregiver. •The experiences of early loss, separation and rejection by the parent or caregiver •Absence of security and emotional absence
  23. 23. Cognitive Theory • Put-forth by Aaron Beck •3 cognitive distortion reality •Negative expectation – Environment – Self – Future •Contrary view
  24. 24. Social Theory •Family –Problems with family –Family stress •Social –Substantial life events –Social isolation
  25. 25. Diagnosis •Clinical Assessment •Behavioral Rating Scales •DSM-IV Criteria and IDS-10 Criteria
  26. 26. Clinical Assessment •By Clinician,trained medical practitioner, psychiatrist or psychologist •Mental state assessment – appearance, behavior speech, mood, memory, and intellectual function •Physical Examination – palpitation in neck, laboratory tests ( TSH, thyroxine, testosterone level) •Other bodily changes
  27. 27. Behavioral Rating Scales •Set of questionnaire for depression assessment •Uses – Screening mental state – Quantifying target symptoms – Determine treatment efficacy •Clinically preferred – Hamilton Rating Scales for Depression (HRS-D) – Montgomery-Asberg Rating Depression Rating Scale –National Institute of Mental Health Diagnostic Interview Schedule (DIS)
  28. 28. DSM-IV Criteria and ICD-10 Criteria •DSM-IV – American Psychiatric Association's revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) •ICD-10 – World Health Organization's International Statistical Classification of Diseases and Related Health (ICD-10)
  29. 29. Treatment •Non-Drug Therapy –Psychotherapy –Phototherapy –Electroconvulsive Therapy •Pharmacotherapy
  30. 30. Psychotherapy •Interpersonal therapy: –assist in solving relationship problems that cause depression •Cognitive-behavioral therapy: – changes the pessimistic ideas and unrealistic expectations –develop positive life goals, and a more positive self-assessment
  31. 31. Electroconvulsive Therapy How is it done? •Pulses of electricity are sent through the brain via two electrodes •Painless procedure •A person is put to sleep with general anesthesia •Muscle relaxers are used to prevent any injury from the procedure Advantages •Quicker effect than antidepressant therapy and thus may be the treatment of choice in several emergency occasions
  32. 32. Pharmacotherapy • Use of antidepressants • Selective serotonin-reuptake inhibitors (SSRIs) like fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram • Tricyclic Antidepressants(TCAs) like amitriptyline, • Monoamine oxidase inhibitors (MAOIs)
  33. 33. References • Young Kimble (2000) et al., Applied Therapeutics: The Clinical Use of Drugs (7th Ed.), Lipincott Williams & Wilkins, Baltimore, pp 77-77-21. • Kasper et al., Harrison’s Principle of Internal Medicine (16th Ed.), McGraw and Hill Companies, New Delhi, pp 2553-2557. • Boyd Nihart (1998) Psychiatric Nursing Contemporary Practice, Lipincott Williams and Wilkins, New York, pp 438-472. • Basavantha BT (2007) Psychiatric Mental Health Nursing (1st Ed.) Jaypee Brothers Medical Publishers Ltd New Delhi, pp 494-521. • URL-1: http:// www.who.int/mental_health/management/depression/definition/en/ (Accessed on October 1, 2010) • URL-2: http://en.wikipedia.org/wiki/Major_depressive_disorder#Symptoms_and_signs • URL-3: http://www.helpguide.org/mental/depression_signs_types_diagnosis_treatment.
  34. 34. THANK YOU

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