1. Trigger:
The patient feels depressed and finds himself waking
up early in the mornings. He has had no previous
physical or psychiatric illnesses. He is a retired
government officer and lives with his wife and two
sons
GROUP C

2. DEPRESSION
Can be defined as;
• Depressed mood on a daily basis for a minimum
duration of 2 weeks.
- Harrison’s principles of internal medicine,
18th edition
• Mental state characterized by feelings of sadness,
loneliness, despair, low self esteem and self
reproach.
- Kaplan and Sadock’s comprehensive
textbook of psychiatry, 9th edition

3. CAUSES
1. GENETIC:
 Risk of unipolar depression in a first degree relative of
a patient is approximately 3% that of not affected.
 Monozygotic twins have a higher concordance rate
(46%) than dizygotic siblings (20%)
2. BIOCHEMICAL:
 Serotonin neurotransmitter system is downregulated.
5HT1a and 5HT2 receptor subtypes are thought most
likely to be involved.
 Dopamine underactivity is also related to
psychomotor retardation.

4. CAUSES
3. HORMONAL:
 Hypercortisolaemia can cause hippocampal damage
which have been found in chronic severe depressive
illness.
 Atypical depressive illness is associated with a
downregulated hypothalamic pituitary adrenal axis.

5. CAUSES
4. NEURAL CHANGES AND NEURONAL GROWTH:
 Increase brain ventrical volume, orbitofrontal,
dorsolateral frontal and anterior cingulate cortex altered
activation
 Hippocampus is smaller in recurrent depression.
5. SLEEP:
 Reduced time between onset of sleep and REM sleep
and reduced slow wave sleep which occur in depressive
illness may be inherited predisposing to depression.

6. CAUSES
6. CHILDHOOD TRAUMAS
 Physical, sexual and emotional abuse or neglect in
childhood predispose adults to depressive illness.
7. PERSONALITY
 Neurotic , emotional and perfectional personality
traits may cause depressive illness which can be
determined by genetic factors and childhood
environment.

7. CAUSES
8. SOCIAL:
 30% of women develop a depressive illness after a severe life event
or difficulty
 Unemployment in men
9. MEDICAL DISORDERS
 Cardiac patients : 20 to 30 %
 Cancer: 25%
 Neurological disorders: Parkinson’s disease, dementia, multiple
sclerosis, traumatic brain injury.
 Diabetes mellitus: 8 to 27 %
 HIV – positive individuals
10. MEDICATIONS
 Corticosteroid therapy
 Antihypertensives
 Anticholesterolemic agents
 Antiarrythmetic drugs

8. RISK FACTORS
• Sex- Females : Male is 2:1
• Death of a relative, assault, or severe
marital or relationship problems.
• Early abuse and neglect to a child
• Number of past episodes

9. Questions to be asked to a patient
• Do you feel depressed?
• Has there been any changes in your self esteem
or from the way you generally value yourself?
• Are you being more self-critical or harder on
yourself than usual?
• Have you dropped many of your activities and
interests?

10. Questions to be asked to a patient
• Do you feel like your life is empty?
• Are you afraid something bad is going to happen
to you?
• Do you often feel helpless?
• Do you think most people are better off (in their
lives) than you are?

11. DIAGNOSTIC CRITERIA FOR DEPRESSION
A. Five (or more) of the following symptoms have
been present during the same 2-week period and
represent a change from previous functioning;
At least one of the first two symptoms must be seen.
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.

12. DIAGNOSTIC CRITERIA FOR DEPRESSION
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly everyday
7. Feelings of worthlessness or excessive or
inappropriate guilt
8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day
9. Recurrent thoughts of death, recurrent suicidal ideation
without a specific plan

13. DIAGNOSTIC CRITERIA FOR DEPRESSION
B. The symptoms do not meet criteria for a mixed
episode
C. The symptoms cause clinically significant distress or
impairment in social, occupational, or other
important areas of functioning.
D. The symptoms are not due to the direct physiologic
effects of a substance or medication.

14. DIAGNOSTIC CRITERIA FOR
DEPRESSION
E. The symptoms are not better accounted for by
bereavement; i.e., after the loss of a loved one, the
symptoms persist for >2 months or are characterized by
• marked functional impairment
• morbid preoccupation with worthlessness
• suicidal ideation,
• psychotic symptoms, or psychomotor retardation

15. PATHOPHYSIOLOGY OF DEPRESSION IN
THIS PATIENT
In the pathophysiology of depression, neuroendocrine,
neurotrophic and monoamine system are interrelated.
a. Increase cortisol
Decrease the expression of post synaptic 5HT1a
receptors in the hippocampus
Decrease in 5HT neurotransmission
Depression

16. b. HPA axis abnormality + steroid abnormality
(increased ACTH & cortisol)
Binding of cortisol to glucocorticoid receptors in
the hippocampus
Suppression of transcription of Brain-Derived
Neurotrophic Factor (BDNF)
Volume loss in hippocampus, medial frontal cortex
and anterior cingulate
Depression

17. LABORATORY INVESTIGATION
1. PERFUSION OR METABOLIC IMAGING
 fMRI
 Positron emission tomography (PET)
 Single proton emission tomography (SPECT)
2. NEUROENDOCRINE CHALLENGE TEST
3. MONOAMINE METABOLITE TURNOVER
4. TRYPTOPHAN DEPLETION
5. SLEEP AND CIRCADIAN RHYTHM(POLYSOMNOGRAPHY)
6. CORTISOL LEVEL(Cushing’s syndrome)

18. LABORATORY INVESTIGATION
To exclude other conditions associated with
depressive moods:
A. TSH level (hypothyroidism)
B. Hematocrit (anaemia)
C. Vitamin B12 level (pernicious anaemia)
D. ALT (liver damage)

19. GROUP C
• Amrit Neupane
• Bibek Jung Thapa
• Dipesh Bikram Shah
• Madan Basnet
• Pratik Silwal
• Rohit Chand
• Sanim Manandhar
• Sumnima Rai
• Sishir Siwakoti
• Mariyam Sama