2. OBJECTI
VES
At the end of lecture students should be able to:
• Explain Depressive Mood disorders and its
various types as given in DSM V
classification.
• Describe prevalence; etiology; risk factors and
D/D of Depressive disorder.
• Formulate a management plan of depressive
disorder based on BIOPSYCHOSOCIAL
MODEL.
3. CASE:
A 42-year-old man comes to his outpatient psychiatrist with
complaints of a depressed mood, which he states is identical to
depressions he has experienced previously.
He was diagnosed with major depression for the first time 20
years ago. At that time, he was treated with imipramine, up to 150
mg/d, with good results. During a second episode, which
occurred 15 years ago, he was treated with imipramine, and once
again his symptoms remitted after 4 to 6 weeks. He denies illicit
drug use or any recent traumatic events. The man states that
although he is sure he is experiencing another major depression,
he would like to avoid imipramine this time because it produced
unacceptable side effects such as dry mouth, dry eyes and
constipation.
•
4. CAS
E
➤What is the psychiatric symptoms and sign in this
case?
➤ What is the best therapy?
➤ What are the side effects of the proposed
therapy?
5. MOOD
DISORDER
• Previously called “affective disorders.”
• The term “mood disorders is preferred today.
• “Mood disorders” refers to disturbance in sustained
emotional states rather than external expression of the
present emotional state’
• A persons emotional state or outlook at particular
time or Generalized state of feeling.
6. Different type of
Mood
• Normal
mood:
Low mood experienced
by healthy people
• Grief
:
• Adjustment
:
Anxiety and depressive
features because of losses
Few mood features
because of life events within
6 months of event
• Depressive
disorder
7. Classification of Depressive
Disorder
• Disruptive Mood Dysregulation Disorder
• Major Depressive Disorder
• Persistent Depressive Disorder
(Dysthymia)
• Premenstrual Dysphoric Disorder
• Substance/Medication-Induced
Depressive Disorder
• Depressive Disorder Due to Another
Medical Condition
• Other Specified Depressive Disorder
• Unspecified Depressive Disorder
8. DSM V Diagnostic
criteria's
A. Five (or more) symptoms for 2-week period and
represent a
change from previous with impaired functioning;
• At least one of the core symptoms is either
1
.
2
.
Depressed mood
Loss of interest or
pleasure.
Associated
symptoms
3
.
4
.
5
.
Significant weight loss when not dieting or weight
gain
children, consider failure to make expected weight
gain.)
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every
9. 6. Fatigue or loss of energy nearly
every day.
7. Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly every
day (not merely self reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness
9. Recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, or a suicide
attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
C
.
The episode is not attributable to the physiological
effects of a substance or to another medical condition.
10.
11.
12.
13.
14.
15.
16. Dysthymic disorder
• A depressive disorder less severe than major depressive disorder
• Chronic depressive symptoms, which are not severe enough to fit
the diagnosis of major depressive episode
• Lasted at least 2 years
Atypical depression
Younger age of onset
More frequent, coexisting with panic disorder, substance-related
problems, and somatic symptoms features
•Mood reactivity (as compared to usual depression’s lack of response
to positive events)
• Overeating
• Oversleeping
• Leaden paralysis
• Sensitivity to interpersonal rejection
17. Minor Mood Disorder
Two-thirds of the psychiatric disorders seen in general practice.
The most frequent symptoms are:
● Anxiety and worrying thoughts
● Sadness and depressive thoughts
● Irritability
● Poor concentration
● Insomnia
● Fatigue
● Somatic symptoms
● Excessive concern about bodily function.
Half of patients with minor mood disorder improve within 3
months
¼ in 6 months.
18. Moderate depressive disorder
• In depressive disorders of moderate
severity the central features are again low
mood, lack of enjoyment, reduced energy,
and pessimistic thinking
• 2 core features and 3 associated
features.
19. Severe depressive
disorder
• All features occurs with greater intensity
• Worthlessness, hopelessness, guilt, ill health OR poverty of
thought.
• Delusions and hallucinations mood-congruent
• A patient with a delusion of impoverishment may wrongly believe
that he has lost all his money in a business venture.
• A patient with nihilistic delusions may believe that he has no future,
or that some part of him has ceased to exist or function (e.g. that his
bowels are wholly blocked—sometimes called Cotard’s
syndrome).
walking corpse syndrome
20. MS
E
Appearance
• The patient’s appearance is often
characteristic Psychomotor retardation.
• Agitation and feeling of restlessness which may
manifest
Mood
• The low mood, diurnal variation of mood
• Anxiety and irritability are frequent.
• Lack of interest and loss of enjoyment (anhedonia)
• no spontaneously.
• No enthusiasm for activities and hobbies that they
would normally enjoy, and describe a loss of zest for
living and for the pleasure from everyday things.
21. MS
E
• Depressive thinking
• Pessimistic thinking (‘depressive cognitions’).
• Thoughts concerned with the present.
• Thoughts concerned with the future.
• Thoughts concerned with the past.
• Depersonalization, obsessional symptoms,
• phobias, and conversion symptoms such as
loss of
function of a limb
23. Prevalence
• Lifetime risk of depressive disorder is around 20% in
both
developed and developing countries
• women than in men: the sex ratio is about 2 to 1.
• Primary care (up to 40% of attenders)
• More common in urban than rural populations
• Depressive disorders cause both direct and indirect
costs to
health services.
• Depression may be undetected, especially when
there are accompanying physical symptoms.
• Unrecognized depressive disorder may slow recovery
and
worsen prognosis in physical illness.
25. Genetic
causes
• Parents, siblings, and children of severely depressed
patients have a higher lifetime risk for mood disorder
(10– 15%) than the general population (1–2%).
• Twin studies of adopted children shows increased risk
of developing the disorder in a child who was born to a
parent with a history of serious depressive disorder.
26. PREDISPOSING ENVIRONMENTAL
FACTORS
• Prolonged diversity of difficulties in marriage or at
work.
• Adverse circumstances seem to prepare the ground for a
final
acute stressor, which precipitates the disorder.
(Example: several young children, poor economic
circumstances, and an unsupportive marriage increase
vulnerability to depression).
• People whoare more vulnerable include:
– Lack of confiding relationships
– Unemployment
27. PRECIPITATING ENVIRONMENTAL
FACTORS
• Depressive disorder follow stressful life events.
• The effect is substantial; the risk of developing a
depressive disorder is increased about six fold in the 6
months after experiencing moderately severe life
events
28. Physical conditions as
predisposing or
precipitating factors
• Most physical conditions are non-specific stressors but a few
appear to precipitate depressive disorder by direct biological
mechanisms. They include:
• Influenza and some other viral infections/ other infection(AIDS)
• Anemia
• Childbirth
• Parkinson’s disease.
• Metabolic syndromes
• Endocrine abnormalities
• Heart diseases
• Epilepsy
• Cancers
• Substance abuse
• Nutritional deficiencies
• Neurological disorders
29. Psychological mediating
processes.
• Two kinds of complementary mediating processes
have
• been studied:
– psychological and biochemical.
1 Abnormalities of emotional processing
2 Tendency to remember unhappy events more easily than happy
ones.
4 Cognitive distortions.
5 Illogical ways of thinking allow the intrusive gloomy thoughts
and the unrealistic expectations to persist despite evidence to
the contrary.
30. Biochemical mediating
processes.
1
2
3
• Strongest evidence is for an abnormality of 5-HT (serotonin) function.
• There are three main strands of evidence.
Concentrations of the main 5-HT metabolite (5-HIAA) are
reduced in the cerebrospinal fluid (CSF)
5-HT concentrations are reduced in the brains of depressed be
caused by drugs used to commit suicide or by post-mortem
changes.
Neuroendocrine functions that involve 5-HT
transmission are reduced in depressed patients.
4 Tryptophan (amino acid precursor of 5-HT) depletion via diet can
lead to
increased depressive mood in people who have recovered.
5 Noradrenergic (NA) function also seems to be reduced in
depressive disorders.
31. MEDICAL CAUSES OF DEPRESSION:
• Pharmacologic: steroids, methyldopa, cimetidine, reserpine,
cyclosporine, amphetamine withdrawal.
• Infectious diseases: Influenza, viral hepatitis, IMN, T.B.
• Endocrinal: Hypothyroidism, Cushing, Addison's,
postpartum, D.M.
• Collagen: SLE, rheumatoid.
• Neurological: parkinsonism, stroke, multiple sclerosis.
• Nutritional: Vit B12, Vit C &D , Folate, Niacin deficiency,
hypercalcemia
• Neoplastic: Cancer head pancreas, disseminated malignancy
32. Endocrine Abnormalities
• Cushing’s syndrome
• Addison’s disease
• Hyperparathyroidism
• hypothyroidism
• childbirth/ menopause /premenstrual syndrome
• Plasma cortisol is increased in about half of patients
with depressive disorder.
• Elevation of cortisol can occur after a prolonged life
stress may predispose to depression by interfering with
brain 5-HT function.
33. Depression: Differences in Women Compared with Men
Parameters Differences in women compared
with men
Lifetime prevalence rate 20 percent (10 percent in men)
Age of onset May be earlier
Duration of episodes May be longer
Course of illness May more often be recurrent
Seasonal effect on mood Greater
Association with stressful life events More frequent
Atypical symptoms of depression (e.g.,
hypersomnia, hyperphagia
Experienced more often
Severity of depression May be greater if self-rated by the
patient
Guilt feelings May be experienced more often
34. Suicidal behavior Suicide attempted more often but
much less often successfully
Association of anxiety disorders,
especially panic and phobic symptoms
Greater
Association of eating disorders Greater
Association of alcoholism and
substance use disorder
Usually less
Association of thyroid disease Greater
Association of migraine headaches Greater
Association of antisocial, narcissistic
and obsessive-compulsive
personalities
Less
Effect of exogenous and endogenous
gonadal steroids on mood
Greater
35. Prognosis
• Two-thirds of those who are depressed never
seek treatment and suffer needlessly.
• 80%-90% of those who seek treatment for
depression can feel better within just a few
weeks.
36. Prognosis
• 80% of the patients with major depression
will experience further episode of depression.
• Average length of each episode is 6 months.
• 25 years follow up shows that on average
patients experience 5 further episodes.
• 1/3 patients do not receive full remission.
39. Investigatio
n
• Detection of depression can be improved if the
doctor always remembers to ask two simple
screening questions:
1 During the last month, have you often been
bothered by feelingdown, depressed, or
hopeless?
2 During the last month, have you often been bothered
by
little interest or pleasure in doing things?
• Diagnosis depends on thorough history taking and
examination of the physical and mental state.
40. Investigatio
n
Diagnosis
● History
● Mental state
● Relevant physical
examination
● Relevant physical
investigation
● Informants’ accounts
Severity
● Biological symptoms
● Psychotic symptoms
● Suicide risk, risk to others
● Effect on social functioning
41. Aetiology
● Psychological
● Social
● Physical illness
● Drug therapy
Social
consequences
● Patient’s everyday
life
● Partner and family
● Dangers at work
Social resources
● Family support
● Housing
● Work
42. Treatment
options
1 Make diagnosis and assess
severity
2 Assess need for hospital treatment or
multidisciplinary team involvement
3 Explain diagnosis, treatment plan, and likely
effect of
treatment (benefits and harms) to patient and
relatives
4 Review after 7 days , Assess side effects, provide
explanation
and reassurance and Monitor every 7–14 days
5 Assess response to treatment by 6 weeks
If better: Continue treatment ,Review need to
44. Indications for SSRI treatment for
depressive
disorder
• Concomitant cardiac disease
• Intolerance to anticholinergic side
effects
• Significant risk of deliberate overdose
• Excessive weight gain with previous
tricyclic treatment
• Sedation undesirable
• Obsessive-compulsive disorder with
depression
46. Tricyclic
antidepressants
• Toxic effects on the cardiovascular system.
• Tricyclic's have been replaced for most purposes by
SSRIs.
• Proven effectiveness in severely depressed patients.
Contraindications
• Agranulocytosis
• Liver damage
• Glaucoma
• Prostatic hypertrophy
• Used cautiously in epileptic
patients.
47. Side effects of Tricyclic
Antidepressants
Anticholinergic effects :
• Dry mouth, Constipation, Impaired visual accommodation
• Difficulty in micturition, Worsening of glaucoma, Confusion
(especially in
the elderly)
Alpha- adenoreceptor blocking effects
• Drowsiness
• Postural hypotension
• Sexual dysfunction
Cardiovascular effects
• Tachycardia
• Hypotension
• Cardiac conduction deficits
• Cardiac arrhythmia
Other effects Seizures
Weight gain
48. Psychological
Treatment
• Support, encouragement, and repeated explanation
that
they are suffering from illness, not moral failure.
• When the depressive disorder appears to have
been precipitated by life problems, discussion and
problem- solving counselling may be required.
• CBT
• When the depressive disorder is severe,
discussion of problems may increase
hopelessness.
• When mood improves, the problems can be
reconsidered.
50. Indications for ECT
1 The need for an urgent response:
(i) when life is threatened in a severe depressive disorder
• Refusal to drink or eat
• Intense suicidal ideation
(ii) Puerperal psychiatric disorders when it is important that the
mother should resume the care of her baby
2
3
Resistant depressive disorder
Failure to thorough treatment with antidepressant
medication.
Two uncommon syndromes
(i) Catatonic
schizophrenia
(ii) Depressive stupor
51. THE ANSWER OF THE CASE (1)
•
• Summary: A 42-year-old man complains of
symptoms of major depression identical to two
prior episodes he experienced in the past.
Previously, he was successfully treated with a
tricyclic antidepressant (TCA), although this class
of medication often produces anticholinergic side
effects such as dry mouth, dry eyes, and
constipation, of which this patient complains. The
question becomes what medication should be used
to treat recurrent major depression when tricyclics
are not an option.
•
52. Best therapy:
• A selective serotonin reuptake inhibitor (SSRI) such as sertraline, paroxetine,
citalopram, fluoxetine, or fluvoxamine is one of the first-line choices of
medication for this patient.
• Selective serotonin norepinephrine reuptakeinhibitors (SSNRI) such as
venlafaxine and duloxetine are also first-line treatment options.
