The document discusses depressive disorders, including major depressive disorder (MDD). Some key points: - Depressive disorders are common worldwide and a leading cause of disability. MDD accounted for 8.2% of disabilities globally in 2010. - Prevalence of depression varies widely between studies but is estimated to be 7.9-15.1% in India. Rates are higher in urban areas, primary care clinics, and the elderly. - Depression is associated with high suicide rates, accounting for 50-70% of suicides. India has high suicide rates, with 37.8% of those committing suicide being under 30.

1. Dr Pradip Mate
(Masters In Pharmaceutical Medicine)

2. • Depressive disorders are common mental disorders that occur in people
of all ages across all world regions
• Depressive disorders are common mental disorders, occurring as early
as 3 years of age and across all world regions
• Global Burden of Disease (GBD) 2010 identified depressive
disorders as a leading cause of burden.
• MDD was also a contributor of burden allocated to suicide and ischemic
heart disease.
• These findings emphasize the importance of including depressive
disorders as a public-health priority and implementing cost-effective
interventions to reduce its burden.
PLoS Med 10(11): e1001547.

3. • Depressive disorders were the second leading cause of YLDs in 2010.
• MDD accounted for 8.2% (5.9%–10.8%) of global YLDs and dysthymia for
1.4% (0.9%–2.0%).
• There was more regional variation in burden for MDD than for dysthymia;
with higher estimates in females, and adults of working age.
• Whilst burden increased by 37.5% between 1990 and 2010
• MDD explained 16 million suicide DALYs and almost 4 million
ischemic heart disease DALYs.
• This attributable burden would increase the overall burden of depressive
disorders from 3.0% (2.2%–3.8%) to 3.8% (3.0%–4.7%) of global DALYs.
PLoS Med 10(11): e1001547.

4. PLoS Med 10(11): e1001547.

7. • Many studies have estimated the prevalence of depression in
community samples and the prevalence rates have varied from
1.7 to 74 per thousand population.
• Reddy and Chandrasekhar carried out a metanalysis, which
included 13 studies on epidemiology of psychiatric disorders
which include 33572 subjects from the community and reported
prevalence of depression to be 7.9 to 8.9 per thousand
population and the prevalence rates were nearly twice in the
urban areas.
Indian J Psychiatry. Jan 2010; 52(Suppl1): S178–S188

8. • large population-based study from South India, which screened more
than 24,000 subjects in Chennai using Patient Health Questionnaire
(PHQ)-12 reported overall prevalence of depression to be 15.1% after
adjusting for age using the 2001 census data
• Studies done in primary care clinics/center have estimated a prevalence
rate of 21-40.45%.
• Studies done in hospitals have shown that 5 to 26.7% of cases attending
the psychiatric outpatient clinics have depression
Indian J Psychiatry. Jan 2010; 52(Suppl1): S178–S188

9. • Studies on the elderly population, either in the community, inpatient,
outpatient and old age homes have shown that depression is the
commonest mental illness in elderly subjects.
• An epidemiological study from rural Uttar Pradesh showed that
psychiatric morbidity in the geriatric group (43.32%) was higher than in
the nongeriatric group (4.66%) and most common psychiatric morbidity
was neurotic depression, followed by manic-depressive psychosis
depression, and anxiety state.
Indian J Psychiatry. Jan 2010; 52(Suppl1): S178–S188

10. Indian J Psychol Med. 2010 Jan-Jun; 32(1): 1–2.

11. • Depression is associated with high suicidality.
• About 50% of individuals who have committed suicide carried a primary
diagnosis of depression.
• Because mood disorders underlie 50-70% of all suicides, effective
treatment of these disorders on a national level should, in principle,
drastically reduce this major complication of mood disorders.
Indian J Psychol Med. 2010 Jan-Jun; 32(1): 1–2.

12. • Indian union health ministry estimates state that 120,000 people commit
suicide every year in India.
• Also over 400,000 people attempt suicide.
• A significant percentage of people who commit suicide in India (37.8%)
are below 30 years of age.
• Ministry officials state that majority of those committing suicide
suffer from depression or mental disorder
Indian J Psychol Med. 2010 Jan-Jun; 32(1): 1–2.

13. • The pooled relative risk of developing IHD in those with major
depression was 1.56 (95% CI 1.30 to 1.87).
• Globally there were almost 4 million estimated IHD disability-adjusted
life years (DALYs), which can be attributed to major
depression in 2010; 3.5 million years of life lost and 250,000
years of life lived with a disability.
• Major depression may be responsible for approximately
3% of global IHD DALYs warrants assessment for
depression in patients at high risk of developing IHD or at
risk of a repeat IHD event
Charlson et al. BMC Medicine 2013, 11:250

14. Cumulative burden of disease of major depression, 2010.
Charlson et al. BMC Medicine 2013, 11:250

15. ● Studies have found high rates of depression in neurological disorders.
● Prevalence of depression after stroke range from 20% to 72%
● In Parkinson’s disease 40-50%
● In Multiple sclerosis 19-54%
● In epilepsy, up to 55%
J Neurol Neurosurg Psychiatry 2011;82:914e923.

16. Journal of the International Neuropsychological Society (2008), 14, 691–724.

17. • Psychological disorders such as anxiety or depression are
common among patients suffering from RA
• It has been calculated that 13.4% have a diagnosis of anxiety
and 41.5% are diagnosed with depression.
• In the case of ankylosing spondylitis, anxiety is present in 25%
of all patients and depression in 15%-30%.
M. Freire et al / Reumatol Clin. 2011;7(1):20–26

18. M. Freire et al / Reumatol Clin. 2011;7(1):20–26

19. • Depression classifications include ;
• Major depressive disorder (MDD),
• Depression with melancholic or catatonic features,
• Atypical depression,
• Psychotic features,
• Bipolar depression,
• Single or recurrent episode,
• Dysthymia
• seasonal affective disorder (SAD).

20. • Clinical and preclinical trials suggest a disturbance in central nervous system
serotonin (5-HT) activity as an important factor.
• Other neurotransmitters implicated include norepinephrine (NE), dopamine (DA),
glutamate, and brain-derived neurotrophic factor (BDNF).
• Functional neuroimaging studies support the hypothesis that the depressed state
is associated with decreased metabolic activity in neocortical structures and
increased metabolic activity in limbic structures.
• Serotonergic neurons implicated in affective disorders are found in the dorsal
raphe nucleus, the limbic system, and the left prefrontal cortex.

21. • Although major depressive disorder can arise without any precipitating
stressors, stress and interpersonal losses certainly increase risk.
• Chronic pain, medical illness, and psychosocial stress
• Older adults may find medical illness psychologically distressing, and these
illnesses may lead to increased disability, decreased independence, and
disruption of social networks.
• Chronic aversive symptoms such as pain associated with chronic medical
illness may disrupt sleep and other biorhythms leading to depression

22. • Impaired social supports
• Caregiver burden
• Loneliness
• Bereavement
• Negative life events

23. • In addition to older age and male sex, risk factors for suicide include
the following :
• Diagnosis of major depression
• Previous history of suicide attempts
• Depressive symptoms with agitation or distress
• Burden of medical disease and the presence of a current serious medical condition
• Recent stressful life events, especially family discord
• Lack of social support
• Being widowed or divorced
• Unexplained weight loss
• High levels of anxiety
• Lack of a reason not to commit suicide
• Presence of a specific plan that can be carried out
• Rehearsal of the plan

24. • A major depressive episode is defined as a syndrome in which at least
5 of the following symptoms have been present during the same 2-
week period :
• Depressed mood (for children and adolescents, this can also be an irritable
mood)
• Diminished interest or loss of pleasure in almost all activities (anhedonia)
• Significant weight change or appetite disturbance (for children, this can be failure
to achieve expected weight gain)
• Sleep disturbance (insomnia or hypersomnia)
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness
• Diminished ability to think or concentrate; indecisiveness
• Recurrent thoughts of death, suicidal
• A pattern of long-standing interpersonal rejection ideation, suicide attempt, or
specific plan for suicide

25. • In depression with melancholic features, either a loss of pleasure in
almost all activities or a lack of reactivity to usually pleasurable stimuli is
present.
• Additionally, at least 3 of the following are required:
• A depressed mood that is distinctly different from the kind that is felt when a loved one
is deceased
• Depression that is worse in the morning
• Waking up 2 hours earlier than usual
• Observable psychomotor retardation or agitation
• Significant weight loss or anorexia
• Excessive or inappropriate guilt

26. • Diagnosis of depressive episodes with catatonic features requires at least
2 of the following, according to the DSM-IV-TR:
• Motoric immobility in the form of catalepsy or stupor
• Motor overactivity that seems purposeless and not in response to
external stimuli
• Extreme negativism or mutism
• Voluntary movement peculiarities such a posturing, grimacing,
stereotypy, and mannerisms
• Echolalia or echopraxia

27. • Adjustment Disorders
• Anemia
• Chronic Fatigue Syndrome
• Dissociative Disorders
• Hypochondriasis
• Hypoglycemia
• Hypopituitarism (Panhypopituitarism)
• Schizoaffective Disorder
• Schizophrenia
• Somatoform Disorders

28. • Longer self-report screening instruments for depression include the following:
• PHQ-9 – The 9-item depression scale of the Patient Health Questionnaire;
each item is scored 0 to 3, providing a 0 to 27 severity score
• Beck Depression Inventory (BDI) – A 21-question symptom-rating scale
• BDI for primary care – A 7-question scale adapted from the BDI
• Zung Self-Rating Depression Scale – A 20-item survey
• Center for Epidemiologic Studies-Depression Scale (CES-D) – A 20-item
instrument that allows patients to evaluate their feelings, behavior, and outlook
from the previous week

29. • Complete blood cell (CBC) count
• Thyroid-stimulating hormone (TSH)
• Vitamin B-12
• Rapid plasma reagin (RPR)
• HIV test
• Electrolytes, including calcium, phosphate, and magnesium levels
• Blood urea nitrogen (BUN) and creatinine
• Liver function tests (LFTs)
• Blood alcohol level
• Blood and urine toxicology screen
• Dexamethasone suppression test (Cushing disease, but also positive in
depression)
• Cosyntropin (ACTH) stimulation test (Addison disease)

30. • Less than 25% of those affected by depression receive
treatment.
• Barriers to effective care include the lack of resources, lack of
trained providers, and the stigma.
• Nearly half of the patients with depression, as in diabetes,
remain undiagnosed for years or inadequately treated.
• Large numbers of patients from rural areas remain under care
of religious healers and may never receive correct treatment.
• The majority of patients do not receive evidence-based
treatments.
Indian J Psychol Med. 2010 Jan-Jun; 32(1): 1–2.

31. • Primary-care-based depression interventions have the potential to reduce
the current burden of depression by 10 - 30%.
• Proactive care strategies incorporating maintenance treatment for
recurrent depression yield considerably greater population-level health
gain than episodic depression
• On efficiency grounds alone, interventions using older antidepressants
are currently more cost-effective than those using newer antidepressants,
particularly in lower-income regions
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