This document discusses depression, including its definition as a layman term, symptom, syndrome, or disorder. It describes the core symptoms of depression and different types including melancholic depression. The continuum of depression is presented, distinguishing depression from normal sadness. Major depressive disorder and dysthymic disorder are explained according to DSM-IV criteria. Theories on the etiology and risk factors for depression are mentioned. A case scenario of postpartum depression with psychotic features is provided and analyzed in terms of diagnosis, etiology, problems, and treatment approach.

1. Depression
Kemurungan
Dr Zahiruddin Othman
MD(UKM) MMed(USM)
Department of Psychiatry

3. Mood Disorders
 A disabling disturbance in
emotion
– Depression
 Sadness
 Feelings of worthlessness and guilt
 Withdrawal from others
 Reduced sleep, appetite, sexual desire
– Mania
 Intense elation
 Hyperactivity
 Talkativeness
 Distractibility
Depressed Mood
Depression
Mania
Elevated Mood

4. What Is Depression?
 Depression has various meanings
 It can be
– A layman term
– A symptom
– A syndrome
– A disorder

5. A Layman Term
 A man was admitted to a medical ward for
an illness. The doctor and nurses noticed
that he was quiet and spent most of his time
on bed. They think he might be depressed...

6. A Symptom
 A man was admitted to a medical ward for
an illness. The doctor and nurses noticed
that he was quiet and spent most of his time
on bed. When asked, he said that he feel
sad because the illness had affected his job.
However, his sleep and appetite were
normal.

7. A Syndrome
 A man was admitted to a medical ward for
an illness. The doctor and nurses noticed
that he was quiet and spent most of his time
on bed. He was sad because the illness had
affected his job. He had disturbed sleep and
lost of appetite for the past 2 weeks.

8. A Disorder
 A man was admitted to a medical ward for
an illness. The doctor and nurses noticed
that he was quiet and spent most of his time
on bed. He feel sad because the illness had
affected his work. He has disturbed sleep
and lost of appetite for the past 2 weeks.
Further history revealed that he had previous
similar episodes in the past and his mother
also suffered from similar illness.

9. Symptom, Syndrome and
Disorder
 A layman term is often based on behavioral
observation only
 A symptom is based on behavioral
description as well as phenomenology
 A syndrome is a recognizable group of
symptoms (number, duration, impairment)
 A disorder is a syndrome with the presumed
etiology

10. Cont.
Layman Symptom Syndrome Disorder
Behavioral
Phenomenology
Threshold
Longitudinal
Etiology presumed

11. Three Approaches to
Psychopathology
 Phenomenological psychopathology
– Objective description, and avoid theories or
assumptions
– Entirely concern with
 Conscious experiences (as the patient experienced
them) and
 Observable behaviors (as others saw them)
 Psychodynamic psychopathology
 Experimental psychopathology

12. Depressive Symptoms
 Core symptoms
– Depressed mood
– Loss of interest or pleasure (anhedonia)
 Psychological and cognitive symptoms
– Feelings of worthlessness
– Excessive/inappropriate guilt
– Diminished ability to think, concentrate or
indecisiveness
– Recurrent thought of death or suicidal
ideation/plan/attempt

13. Cont.
 Biological, somatic, behavioral or
neurovegetative symptoms
– Weight loss/gain or increase/decrease appetite
– Insomnia or hypersomnia
– Psychomotor agitation/retardation
– Fatigue or loss of energy

14. Continuum of Depression
Threshold for MDE
MDE as part of Major Depressive Disorder
MDE as part of Bipolar Disorders
Depressive Disorder NOS
Dysthymic Disorder
Adjustment Disorder With Depressed Mood
Bereavement
Normal sadness

15. Depression Compared
to Normal Sadness - 1
 Intensity: The mood change pervades all
aspects of the person and impairs social and
occupational functions
 Absence of Precipitants: The mood may
arise in the absence of any discernible
precipitant or may be grossly out of
proportion to those precipitants

16. Depression Compared
to Normal Sadness - 2
 Quality: The mood change is different from
that experienced in normal sadness
 Associated Features:The change in mood
is accompanied by a cluster of signs and
symptoms, including cognitive and somatic
features
 History: The mood change may be
preceded by a history of past episodes of
elation and hyperactivity

17. DSM-IV Major Depressive
Episode
 Inclusion (must be present)
– Number: 1 core symptom plus at least 4 other
symptoms of depression
– Duration: 2 weeks
– Impairment: significant distress or social
occupational impairment
 Exclusion (must be absent)

18. Cont.
 Exclusion
– Not a mixed episode
 Bipolar disorder
– Not due to direct physiological effect of a
substance or GMC (e.g., Hypothyroidism)
 Mood disorder DTGMC
 Substance-induced mood disorder
– Not better accounted (NBA) for by
bereavement

19. It Is NBA for by Bereavement If...
 Symptoms persist for longer than 2 months
after loss of the loved one
 Marked functional impairment
 Morbid preoccupation with worthlessness
 Suicidal ideation
 Psychotic symptoms
 Psychomotor retardation

20. Disorders With Depression As
Main Symptoms
 In response to psychosocial stressor
– Bereavement
– Adjustment disorders with depressed mood
 Mood disorders
– Depressive disorders (unipolar depression)
– Bipolar disorders
– Secondary mood disorders
 Mood disorder DTGMC
 Substance-induced mood disorder

21. Depressive Disorders
 Major depressive disorder (MDD)
 Dysthymic disorder
 Depressive disorder not otherwise specified
(NOS)

22. DSM-IV Major Depressive
Disorder
 Inclusion
– Presence of at least a Major Depressive Episode (MDE)
 Exclusion
– Other mood disorders
 No previous manic, hypomanic or mixed episode
– Psychotic disorders
 Not better accounted by schizoaffective disorder
 Not superimposed on schizophrenia, schizophreniform
disorder, delusional disorder, or psychotic disorder NOS

23. Cross Sectional and
Longitudinal
Past Present
CROSS SECTIONAL
(Inclusion)
MDE

24. Cross Sectional and
Longitudinal
Past Present
LONGITUDINAL
(exclusion)
CROSS SECTIONAL
MDEMDE
Major depressive
Disorder (MDD)

25. Cross Sectional and
Longitudinal
Past Present
LONGITUDINAL
CROSS SECTIONAL
MDEMania
Bipolar disorder

26. Course of Unipolar
Depressive Illness
M
O
O
D
T I M E

27. DSM-IV Dysthymic Disorder
 Inclusion
– Depressed mood for 2 years plus 2 or more
following symptoms
 Poor appetite or overeating
 Insomnia or hypersomnia
 Low energy or fatigue
 Low self-esteem
 Poor concentration or difficulty making decision
 Feelings of hopelessness

28. Cont.
 Exclusion
– Other mood disorders
 No MDE in 2 years (NBA chronic MDD or MDD, in partial
remission)
 No manic, hypomanic or mixed episode
 Not cyclothymic disorder
– Chronic psychotic disorders e.g., schizophrenia or
delusional disorder
– Secondary disorders: GMC or substance-induced

29. Dysthymic Disorder
M
O
O
D
T I M E

30. Double Depression
M
O
O
D
T I M E

31. Depressive Disorder NOS
 Premenstrual dysphoric disorder
– Regularly occurred during the last week of the luteal
phase and remitted within few days of menses
 Minor depressive disorder
– 2 weeks of depression but < 5 symptoms
(insufficient number of symptoms for MDE)
 Recurrent brief depressive disorder
– Depressive episode lasting from 2 days up to 2 weeks
(insufficient duration of symptoms for MDE)

32. Cont.
 Postpsychotic depressive disorder of
schizophrenia
– A MDE occurs during residual phase of
schizophrenia
 A MDE superimposed on delusional
disorder, psychotic disorder NOS or active
phase of schizophrenia

33. Cross Sectional and
Longitudinal
Past
LONGITUDINAL
CROSS SECTIONAL
MDE
Schizophrenia
Postpsychotic
depression
of schizophrenia
Present
Residual phaseActive phase

34. A Systematic Scheme for the Clinical
Description of Mood Disorders
The Episode
Severity Mild, moderate, or severe
Type Depressive, manic, or mixed
Special
features
Melancholic, neurotic, psychotic,
agitation, or retardation/stupor
The Course Unipolar or bipolar
Etiology Predominantly reactive or endogenous
Oxford Textbook of Psychiatry, 3rd edition, pg 209

35. Classification of Depressive
Disorders
ICD-10 DSM-IV
Depressive episode
Mild, moderate, severe, or severe with
psychosis
Major depressive episode
Mild, moderate, severe, or severe with
psychosis
Other depressive episode
Atypical depression
Recurrent depressive episode Major depressive disorder
recurrent
Persistent mood disorders
Cyclothymia and dysthymia
Dysthymic disorder
Other mood disorders
Recurrent brief depression
Depressive disorder NOS
Recurrent brief depression
Oxford Textbook of Psychiatry, 3rd edition, pg 208

36. Clinical Features of Melancholic
and Somatic Depression
 Melancholic features (DSM-IV)
– Loss of interest or pleasure in usual activities*
– Lack of reactivity to pleasurable stimuli*
Plus at least three of the following
– Distinct quality of mood (unlike normal sadness)
– Morning worsening of mood*
– Early morning waking*
– Psychomotor agitation or retardation*
– Significant anorexia or weight loss*
– Excessive guilt
– Marked loss of libido* (ICD-10)
*Somatic symptoms of depression in ICD-10 (at least 4 required for diagnosis)
Oxford Textbook of Psychiatry, 3rd edition, pg 205

37. Psychotic Features
Severe with psychotic features
mood-incongruent
mood-congruent
Severe without psychotic features
Moderate
Mild

38. Cont.
 Mood-congruent psychotic features
 Delusions of guilt
 Delusions of deserved punishment
 Nihilistic delusions (Cotard’s syndrome)
 Somatic (hypochondriacal) delusions
 Delusions of poverty
 Auditory hallucinations – usually transient, not
elaborate, repetitive words and phrases

39. Cont.
 Mood-incongruent psychotic features
– Less common
– Associated with poorer prognosis
– Persecutory delusions (without depressive
themes that he/she should be persecuted)
– Delusions of thought insertion/broadcasting or
delusion of control

40. Other Features
Prominent features
Agitated depression Agitation
Retarded depression Psychomotor retardation
Depressive stupor Stupor, may have catatonia
Masked depression Somatic complaints
Atypical depression Mood reactivity, weight gain,
increase appetite,
hypersomnia, interpersonal
rejection sensitivity

41. Epidemiology of Bipolar and
Unipolar Disorder
Bipolar
disorder
Unipolar
disorder
Lifetime risk About 1% 5%-10%
Sex ratio (M:F) 1:1 1:2
Average age of
onset
21 yrs 27 yrs
Oxford Textbook of Psychiatry, 3rd edition, pg 212

42. Some Etiological Factors in
Major Depression
Genetic
Family history of depression
Early development
Parental discord in childhood
Childhood abuse
Personality
Neuroticism
Environmental factors
Recent stressful life events
Lack of social support
Oxford Textbook of Psychiatry, 3rd edition, pg 213

44. Theories on Etiology
Psychological
Psychoanalytic
Behavioral
Cognitive
“Loss of loved object” (Freud)
Learned helplessness (Seligman)
Depressive cognition (Beck)
Biochemical
Monoamines Serotonin, noradrenalin, dopamine
Endocrine
HPA axis
Thyroid

45. Attributions for Negative Events

46. Cognitive Risk Factors for
Depression:
Internal, Global, Stable

48. Neurotransmitters in Mood Disorder
Dopamine Norepinephrine
Serotonin
drive zeal
motivation
alertness
energy
mood
GABA
Enkephalins
Endorphins
Na channels
Glutamate
impulse

49. Phase of Treatment
Phase Aim
Acute Reduction of symptoms
Continuation Prevention of relapse
Maintenance
(prophylaxis)
Prevention of recurrence

50. 5-4 Stahl S M, Essential
Psychopharmacology (2000)
acute
6 - 12 weeks
continuation
4-9 months
maintenance
1 or more years
TIME
DEPRESSION
NORMAL
MOOD RELAPSE RECURRENCE

51. Type of Treatment
Pharmacotherapy
Antidepressant – TCA, SSRI, MAOI
Physical
Electroconvulsive therapy (ECT)
Psychotherapy
Dynamic, marital, interpersonal, CBT
Other
Sleep deprivation, bright light therapy

52. Some Problems and Treatment
Patient Problem Treatment
Suicidal
Immediate risk of
suicide
Pharmacotherapy ~ 2 weeks
ECT has faster onsetPostpartum
Risk of infanticide,
poor baby care
Stupor Poor oral intake
Psychotic Psychotic Add antipsychotics
Elderly
Diagnosis, prone to
side-effects
Cautious of drug interaction
Less anticholinergic s/effect

53. Predictors of Suicide

54. Case Scenario
 30 years old female, para 4. Just delivered a
baby boy 2 months ago. Complaint of
feeling sad, lethargic, loss of appetite and
terminal insomnia since 2 weeks after
delivery. Past 2 weeks condition worsen –
insist that the baby should not be born as he
would live in poverty. She also heard voices
repeatedly condemning her for not being a
good mother.

55. Cont.
 She had similar episodes during the
previous childbirth but resolved without
hospital treatment in a few months time.
Husband, a lorry driver, frequently went for
outstation for days. Modest income and
does not help much with bringing-up of the
children. Family history: her mother died of
suicide after a marital discord.

56. Symptom  Syndrome
 Symptoms
– Sad
– Insomnia
– Loss of appetite
– Fatigue
– Hallucinations and ?delusions
 Duration
– Onset 2 weeks of childbirth
– Duration 6 weeks
 Impairment

57. Syndrome  Diagnosis
 Cross sectionally
– Does it qualify as MDE?
 Sufficient number, duration and impairment
 Not mixed episode, no secondary/organic causes,
NBA for by bereavement
 Longitudinally
– Does it better accounted by another mental
disorder?
 Is there previous mood episodes?
 Is there underlying psychotic disorders?

58. Etiology
Biological Psychosocial
Predisposing Genetic
Parental discord
Long-term difficulties
Precipitating Childbirth

59. Postpartum Mental Disorders
Postpartum psychoses
1. Organic
2. Mood
a. unipolar
b. bipolar
3. Schizophrenic

60. Diagnosis
 Major depressive disorder recurrent
– Severe with mood-congruent psychotic features
– With postpartum onset

61. Problems
 Postpartum onset
– Childcare, mother-child bonding, future
relapse, infanticide
 Psychotic
– Severe depression, future episode, recovery
 ?Marital relationship, husband support
– Precipitating  perpetuating factors

62. Treatment
Acute
Antidepressant + antipsychotic
Psychoeducation, ECT, family
therapy
Maintenance
Antidepressant, psychoeducation
Family planning

63. References
 Oxford Textbook of Psychiatry, 3rd Edition
 DSM-IV, 4th Edition
Thank You