Dr. Arun Chopra will present a lecture on depressive disorders covering their history, validity, symptoms, classifications, epidemiology, and etiology. The lecture aims to help understand depressive disorders, prepare for exams, and consider the broader context. It will likely cover management approaches in the next session. The summary will focus on the high-level topics to be covered rather than specific details about depression.

1. MRCPsych Masterclass
Dr Arun Chopra
Consultant Psychiatrist, NottsHC
Depressive Disorder

2. Dying is an art.
Like everything else,I
do it exceptionally
well.
I do it so it feels like
hell.
I do it so it feels
real.
I guess you could
say I have a call.

3. Lecture Scope

4. Lecture Scope
History
Validity
Symptoms
Classifications
Epidemiology
Aetiology
Management- probably
next session

5. Lecture Scope
History
Validity
Symptoms
Classifications
Epidemiology
Aetiology
Management- probably
next session
Understand Depressive
Disorders
Prepare for the Exams
Think about the wider
context in which we

6. History, Validity?, Symptoms
4

7. History, Validity?, Symptoms
4

8. History, Validity?, Symptoms
4

9. History, Validity?, Symptoms
4

10. History, Validity?, Symptoms
4

11. Classification
• Reactive( • Melancholic(
• Endogenous( • Neurotic(
Presumed( Symptomatic(
aetiology( picture(
International(
Course(
classifications(
• Unipolar( • ICD%10(&(11(
• Recurrent( • DSM(IV(&(V(
• Bipolar(

12. Epidemiology
Depression Bipolar
Lifetime risk 10-20% About 1%
Sex ratio (M:F) 1:2 1:1
First-degree relatives:
Lifetime risk for bipolar About 10% About 25%
Lifetime risk for unipolar 20-30% 20-30%
depression of onset
Average age 27 years 21 years
Suicide 10% 15%

13. Aetiology
life events unknown
others
vulnerability
genetics

14. Life events
Life events precede the onset of
depression
Losses precede 20% of cases
Many suffer depression with no
significant preceding life event
Genetic, developmental,
temperamental predispositions ?

15. Vulnerability factors
Factor
Family history High risk in families with history of depression
(7%) or alcoholism (8%)
Social class No relationship
Life events Recent negative life events may precede
Personality episode worries, introverted, stress sensitive,
Insecure,
obsessive, unassertive, dependant
Childhood experience Early childhood trauma (e.g. significant loss,
disruptive, hostile, negative environment)
Postpartum Depressive episodes common
Menopause No relationship
Social network Relative lack of interpersonal relationships

16. Mediating factors?
Mediating factor
HPA axis
Genetics
Kindling (for later
episodes)
Neuroticism, Extraversion?

17. pax203x100.j

18. resilience

19. Pathophysiology: biological
theories
mono-
amines
HPA Early
axis Life

20. Early life stress
Physical
abuse
Emotiona Long lasting effects
l abuse on:
Neuroendocrine
Psychophysiological
Neglect Neurochemical
Parental
loss

21. Neurotransmitters

22. Neurotransmitters

23. Support for the
hypothesis
Criticism
17

24. Other biochemical hypothses
Dopamine Choline GABA
Peptides (TRH,
Phenylethylamine cAMP
beta-endorphin)
Folic acid SAM Histamine

25. Emotional trauma
(neuroendocrine)
Psychological)disturbance)
Depressive)disorder)
Emotional)trauma) Cushing’s)disease)
Thyroid)disease)
Mood)&)Cognition)

26. HPA axis (neuroendocrine)
Dexamethasone(Suppression(Test(
Increased(CSF(CRH(
Increased(ACTH(
Altered(circadian(rhythm(of(cortisol(
Cortisol( secretion(
hypersecretion( Resistance(to(glucocorticoid(
feedback(inhibition(of(ACTH(
Blunted(ACTH(response(to(CRH(
Increased(plasma(and(urinary(
metabolites(
Increased(adrenal(gland(size(

27. Abnormal DST and psychiatric
diagnoses
Psychiatric condition Result (%)
Melancholia 45
Mania 0-40
Schizophrenia 0-20
Panic disorder 25
OCD 2
Anorexia nervosa 36-100
Bulimia 35-67
Borderline PD 8
Normals 4-27

28. DST non-suppression and
affective state
Affective state % non-suppression
Normal control 7.2
Acute grief 9.5
Dysthymic disorder 22.9
Major depressive disorder 43.1
Melancholia 50.2
Psychotic affective, + bipolar 68.6
With suicidal intent 77.8

29. False positive DST
Medication Diseases Metabolic
• Benzodiazepines • DM • Dehydration
• Anticonvulsants • Dementia • Pregnancy
• Barbiturates • Cerebral tumour • Acute medical
• Reserpine • Cardiac failure illness
• Alpha-methyl • Cushing’s disease
dopa
• Methadone
• Morphine
• Spironolactone
• Indomethacin
• Excessive caffeine
• Alcohol

30. HPT axis (neuroendocrine)
Depression&and&cognitive&decline&in&adult&
hypothyroidism&
T3&effects&on&antidepressant&
Dynamic&reduction&in&plasma&thyroxine&in&depressed&
patients&using&various&somatic&treatments&
Effect&of&thyroid&hormones& Administering&TRH&induces&a&sense&of&wellbeing&and&
on&mature&brain&functions& relaxation&
Flattening&of&the&diurnal&TSH&curve&
Blunted&TSH&response&to&administration&of&TRH&
Subclinical&hypothyroidism&/&Positive&antithyroid&
antibodies&

31. Neuroimaging in depression
Neocortical)
deactivation)
Limbic)activation) • Right)prefrontal)cortex)
• Inferior)parietal)
• Subgenual)cingulate) • Left)prefrontal)cortex)
• Anterior)insula)
• Amygdala)
Basal)ganglia)
deactivation)
• Caudate)
• Putamen)
Depression)

32. Stress, antidepressants & ECT
hippocampus

33. Sleep
Patient symptoms Non-REM
! Increased stage 1
!Difficulty getting off ! Decreased stages 3 &
to sleep 4
!Poor sleep
!EMW REM
! Decreased REM
!Increased waking
latency
!Decreased total
! Increased REM time in
time early hours
! Decreased REM in late

34. Psychosocial theories
Psychoanalytic, Psychodynamic,
Behavioural,models,
Karl,Abrahams, Sigmund,Freud,
1950,
1911, 1920,
Inadequate,positive,
Depression,is, reinforcement,–,
unconsciously, Precipitated,by,loss, Peter,Lewinsohn,
motivated,
Learned,
helplessness,–,
Martin,Seligman,
Repressed,sexual,
and,aggressive, Regressions,to,anal,
Cognitive,
drives,against,the, or,oral,phases,
behavioural,model,–,
self,
Aaron,Beck,

35. Cognitive Behavioural Model
Cognitive)
Distortions)
Arbitrary)
inference)
Negative(self,
view(
Selective)
abstraction)
Cognitive(
Triad(
Magnification)
Negative(
Negative(view(
interpretation( Minimisation)
of(the(future(
of(experience(

36. Genetic epidemiology of
depression
1.5 – 3x of
Inherited
Nature / MDD if first
vulnerability to Hereditability
Nurture degree relative
depression
MZ twins raised Increased Higher with
Increased risk
together 76% chance with recurrent
of bipolar
MDD further relative depressive
MZ twins raised DZ twins 19% Adoption
apart 67% MDD MDD studies

37. Associati0n studies of candidate
genes
! Number of genes
! Inconsistency of
findings
! Certain genes in certain
families
! Candidate genes
! Monoaminergic
! Gene / Environment
interactions
! Genetic linkage studies
! Chromoses involved in
susceptibility
1,3,4,6,8,11,12,15,18

38. Candidate Genes
Serotonin Serotonin 2A Tryosine
transporter receptor hydroxylase
(SLC6A4) (5HTR2A) (TH)
Catechol-o- Tryptophan
5-HTTLRP long methyltransfera hydroxylase 1
and short form se (COMT) (TPH1)
(regulates
serotonin)
BDNF

39. Sex differences in symptoms
Symptom %male %female
Depressed mood 100 100
Loss of interest 99.6 98.8
Anxiety, psychic 97.1 97.8
Anxiety, somatic 87.4 94.2
Insomnia, initial 83.7 87.3
Suicide 82.0 83.5
Somatic, general 82.0 80.4
Somatic, GI 80.3 77.7
Insomnia, delayed 74.1 72.7
Guilt 71.5 71.9
Insomnia, middle 71.5 71.9
Weight loss 69.0 68.8

40. Sex differences in symptoms
Symptom %male %female
Agitation 68.1 68.1
Libido 59.8 49.5
Retardation 52.3 43.5
Hypochondriasis 33.1 25.8
Loss of insight 28.0 21.9
Paranoid symptoms 25.1 21.1
Obsessional symptoms 13.3 20.7
Depersonalisation 10.9 13.8
Diurnal variation: 59.4 60.1
Worse in morning 61.4 60.1
Worse in evening 30.7 25.0
Worse in afternoon 7.9 9.5

41. Bipolar and unipolar differences
Bipolar Unipolar
Substance abuse +++ +
Family history ++++ +
Seasonality ++++ +
Onset before age 25 +++ +
Postpartum onset +++ +
Psychotic depression <age 35 +++ --
Atypical features ++++ +
Rapid on/off pattern ++ --
Recurrent MDE’s ++ +
Antidepressants associated with hypomania / ++ --
mania
Brief episodes of depression ++++ --
Antidepressant wear-off ++ --
Mixed depression ++ --

42. Rating scales for depression
Major Hamilton Montgomery-
Beck Depression
Depression Depression Asberg
Inventory
Inventory Scale Depression
Zung Self-
Hospital Center for Burns
Rated
Depression and Epidemiological Depression
Depression
Anxiety Scale Studies Checklist
Depression Depression Cornell Scale for Reynolds
Scale of Outcomes Depression in Adolescent
Goldgerg Module Dementia Depression

43. Course of depression
Age of onset
• Average age of onset mid teens to late 20s
• Preceded by dysthymic disorder in 10-25% cases
Duration of episode
• Symptoms develop over days to weeks, with prodromals and comorbids
• 18% > 1 year
Recovery
• 50% will develop recurrent depressive disorder with variable outcome
• 5-10% do not recover from first episode; 5% become bipolar
Long term outcome
• More benign in one third of patients
• Length of cycle shortens with more frequent episodes
Mortality and suicide
• Up to 15% commit suicide
• Need figures on DSH

44. Differential diagnoses

45. Differential diagnoses
Uncomplicate Other
d Medical
psychiatric
bereavement conditions
disorders

46. Differential diagnoses
Uncomplicate Other
d Medical
psychiatric
bereavement conditions
disorders
Medicati Substanc Neurolog Infectiou Neoplas Metaboli Collagen Miscella
ons e abuse ical s disease ms c& - neous
disease endocrin vascular
e conditio

47. Management options (some)
Stress
Watch and wait Counselling Exercise
management
ECT Medication Mindfulness CBT / IPT …
Psychosocial Behavioural Rare -
Self help
approaches activation neurosurgery

48. Other issues
Drugs
CSF
EEG studies
Structural brain
DSM-V & ICD-11
Spiritual & Philosophical
Evolutionary