STRESS AND DEPRESSION Treatment and management

2. STRESS AND DEPRESSION
BY AMMARA BATOOL.

3. Group members
AMMARA BATOOL
MUNAWAR SULTANA
PALVASHA GILANI

4. Table of contents
Understanding “STRESS and
DEPRESSION”.
Treatment and Management
protocol.
Non-Pharmacological.
Pharmacological.

5. Stress
Stress: (roughly the opposite of relaxation)
• it is a medical term used for a wide range of
strong external stimuli, both physiological and
psychological, which can cause a physiological
response called the general adaptation
syndrome.
• First described in 1936 by Hans Selye in the
journal Nature.

6. Stress
• People with a type A personality which is typically
hostile, aggressive, striving and competitive, may
be more at risk than other diseased patients.
(Jenkins, 1978; Rosenman and Chesney, 1980).
• "Like email and email spam, a little stress is good
but too much is bad; you'll need to shut down
and reboot," says Esther Sternberg.

7. Causes of stress.
•Your health .
•Emotional problems .
•Your relationships .
•Major life changes .
•Stress in your family .
•Conflicts with your
beliefs and values .
•Social and job issues that
can cause stress .

8. .
Symptoms of stress
The symptoms of stress can be either physical or
psychological .
1) Stress-related physical illnesses, such as :
•Irritable bowel syndrome.
•Heart attacks .
•Arthritis .
•Chronic headaches, result from long-
term overstimulation of a part of the nervous
system that regulates the heart rate, blood press
ure, and digestive system.

9. .
2) Stress-related emotional illness results from
inadequate or inappropriate
responses to major changes in one's life situation,
such as
•Marriage .
•Completing one's education .
•Becoming a parent .
•Losing a job, or retirement.

10. Stress
3)Psychiatrists sometimes use the term adjustment
disorder to describe this type of illness.
• In the workplace, stress-
related illness often takes the form of burnout—
a loss of interest in or
ability to perform one's job due to long-
term high stress levels.

11. Stress
Work-related stress:
• Work-related stress is the response people may have when presented
with work demands and pressures that are not matched to their
knowledge and abilities and which challenge their ability to cope.
• Stress occurs in a wide range of work circumstances but is often made
worse when employees feel they have little support from supervisors and
colleagues, as well as little control over work processes.
• There is often confusion between pressure or challenge and stress and
sometimes it is used to excuse bad management practice.

12. General symptoms (patient’s
perspective)
•A fast heartbeat.
•A headache.
•A stiff neck and/or tight
shoulders.
•Back pain .
•Fast breathing.
•Sweating and sweaty palms.
•An upset stomach, nausea,
or diarrhea .

13. Stress
How stress affects your thoughts and emotions (patients).
• You might notice signs of stress in the way you think, act, and feel. You
may:
• Feel cranky and unable to deal with even small problems.
• Feel frustrated, lose your temper more often, and yell at others for no
reason.
• Feel jumpy or tired all the time.
• Find it hard to focus on tasks.
• Worry too much about small things.
• Feel that you are missing out on things because you can't act quickly.
• Imagine that bad things are happening or about to happen.

14. Signs and symptoms : (healthcare
professionals)
1. Symptoms of acute stress: in the first
month after a potentially traumatic
event, with the following subtypes:
2. Symptoms of acute traumatic stress:
(intrusion, avoidance and hyper arousal)
in the first month after a potentially
traumatic event.
3. Symptoms of dissociative: (conversion)
disorders in the first month after a
potentially traumatic event.
4. Non-organic (secondary) enuresis: in the
first month after a potentially traumatic
event (in children).

15. Stress
Organ system effect (health professionals)
 Immune system: Constant stress can make you more likely
to get sick more often. And if you have a chronic illness
such as AIDS, stress can make your symptoms worse.
 Heart : Stress is linked to high blood pressure, abnormal
heartbeat arrhythmia, blood clots, and hardening of
the arteries (atherosclerosis) It's also linked to coronary
artery disease, heart attack, and heart failure.
 Muscles: Constant tension from stress can lead to
neck, shoulder, and low back pain. Stress may
make rheumatoid arthritis worse.

16. Stress
 Stomach If you have stomach problems, such as
gastroesophageal reflux disease (GERD), peptic ulcer
disease, or irritable bowel syndrome, stress can make your
symptoms worse.
 Reproductive organs Stress is linked to low fertility,
erection problems, problems during pregnancy, and
painful menstrual periods.
 Lungs Stress can make symptoms of asthma and chronic
obstructive pulmonary disease (COPD) worse.
 Skin Skin problems such as acne and psoriasis are made
worse by stress.

17. Depression:
“Sustained or chronic stress, in
particular, leads to elevated
hormones such as cortisol, the
"stress hormone," and reduced
serotonin and other
neurotransmitters in the brain,
including dopamine, which has
been linked to depression”.
.

18. •When the stress response fails to
shut off and reset after a difficult
situation has passed, it can lead
to depression in susceptible
people.
•When these chemical systems are
working normally, they regulate
biological processes expressions
of normal moods and emotions.

19. TYPES DEFINATION
Dysrthymic disorder It is also known as persistent depressive
disorder. Patients display depressed mood or
sadness that persists for the majority of the
duration of the day for a minimum of two
years in adults and one year in children and
adolescents
MDD Patients with this type of depressive disorder
typically show dysphoric mood and
anhedonia accompanied by physical changes
such as weight loss or gain, increased or
decreased appetite, alteration in sleep
pattern and sustained fatigue.
Melancholic depression There is an almost absolute lack of ability to
experience pleasure.

20. TYPES DEFINATION
Seasonal affective
disorder (SAD)
It is a type of depression described as
recurring annually during fall or early winter.
Post-partum depression
(PPD)
This describes a heterogeneous group of
depressive symptoms that affects mothers.
These symptoms may surface before or after
giving birth
Psychotic depression is a type of depressive disorder which is very
severe and accompanied by psychotic
symptoms

21. Causes:
•Chronic stress
•Early Life Trauma or abuse.
•Gene-Environment Interactions.
•Loneliness.
•Lack of social support.
•Financial strain.
•Marital or relationship
problems.
•Unemployment or
underemployment.
•Alcohol or drug abuse.
•Health problems and chronic
pain.

22. Stress
Pathophysiology of stress and depression :
(healthcare professionals)
• Stress and depression are associated with atrophy
and loss of neurons in limbic and cortical brain
regions that could contribute to the symptoms of
depression. Clinical research has consistently
reported that depression and other stress-related
illnesses are associated with decreased volume,
neuronal atrophy, and altered connectivity of the
prefrontal cortex PFC .

24. Stress
Organ systems and hormones involved are;
• Neural circuitry of depression.
• Stress response circuits.
• Genetic vulnerability and environmental interaction.
• The biogenic monoamine theory. (role of
neurotransmitters)
– The Serotonin hypothesis.
– The catecholamine hypothesis.
• Inflammation and depression.
• The physiologic response to stress is partly gender-
specific: women show generally greater stress
responsiveness than men.

25. STRESS DEPRESSION
Depression hopelessness
Apathy Lack of enjoyment
Denial sadness
Anxiety of fever worthlessness
Guilt Guilt
Grief Emptiness

27. TREATMENT

28. Non Pharmacological Treatment

29. Behaviour activation therapy
1.Recognizing depression
Minor depression is the presence
of at least 2 depressive symptoms
(1 symptom must be either
depressed mood or loss of interest)
during the same 2-week period,
with no history of a major
depressive episode

30. Major depression is the depressed
mood or loss of interest or irritability
with 5 or more depressive symptoms
 significant weight loss or weight gain
decrease or increase in appetit
 insomnia or oversleeping
feelings of agitation or irritability
fatigue or loss of energy
feelings of worthlessness or
excessive or inappropriate guilt

31. 2. Rationale for BATD
• After recognition of determine the best approach
• In healthy behavior
• Dec depressed behavior.
• Assessing reasons for your depressed behavior
depression
• which often is the result of natural responses to
stressful
• environmental situations and change
3. Getting started
•Identifying potential activities
•Carrier ,education ,health, family and social relationship
•Selecting activities

35. Cognitive behavior therapy
person's mood is directly related to his or
her patterns of thought.
to recognize negative patterns of thought,
evaluate their validity, and replace them
with healthier ways of thinking.
aim to help their patients change patterns
of behavior that come from dysfunctional
thinking.

36. Cognitive behavior therapy
cognitive behavioral therapy
Cognitive restructuring refers to the
process in CBT of identifying and changing
inaccurate negative thoughts that
contribute to the development of
depression.

37. Cognitive behaviour therapy
For instance, a college student may have failed a math quiz and
responded by saying, "That just proves I'm stupid."
Always thinking the worst is going to happen
Always putting the blame on oneself even when there is no
involvement in something bad that happened
type of person likely to get the most benefit is someone who:
•Is motivated
•Sees him or herself as able to control the events that happen
around them
•Has the capacity for introspection

38. 3. Interpersonal therapy
IPT is founded on the hypothesis that
the crucial factor in depression is the
social network of the patient
Addresses interpersonal issues in
depression exclusion of other clinical
attention

39. 1st stage 1 to 3
review past episodes
Then shift to communication analysis:
who said what, to whom, and what
was the effect? Be specific
clarification {what I think you said
was…..}
communication skills education {you
said it how????}
information {most are clueless about
psychiatric conditions}

40. Educate
First job is to educate the patient about depression, have them
accept it, and legitimize the sick role for awhile, while not
fostering dependency
Suggest that patient still work and socialize as much as possible
“You are depressed, it is a real condition, not weakness or just a
bad day. But while we work on it, you need to stay active and not
cave in or withdraw.”

41. 2nd stage
Focus on four interpersonal problems areas as suggested by
Klerman, take one and work it through, with one area as a
possible back up:
1. Interpersonal Role Disputes
These tend to occur in marital, family, social or work settings. • A
situation in which the patient and other parties have diverging
expectations of a situation and that this conflict is excessive
enough to lead to significant distress.

42. 2. Role Transitions
Patient has to adap a change in life
circumstances
3. Grief
The therapist will help to reconstruct the
patient's relationship with the deceased and by
encouraging affect as well as clarification and
empathic listening help facilitate the mourning
process with the aim of helping the patient to
establish new relationships.
Final stage
Pulling together what was learned, preparing
for termination
Understanding that upsurge of symptoms is
normal and does not mean that the depression
is necessarily recurring

43. Assess maladaptive relationships
Reconstruct them Where possible, restore past losses
Cope with immediate stressful interactions
Form better or new relationships
Master new problem solving and social skills to keep them
Minimize dependency on others
Increase self-esteem, reduce chance of future depression

44. Mindfulness-based cognitive
therapy
The program is intended to train the mind and body to
respond more constructively to experiences in hopes of
preventing another slide into depression,
MBCT is a structured program that includes eight
weekly, 2-hour group sessions.
Patients are assigned homework on a daily basis.
Homework consists of awareness exercises designed to
help patients improve “
This includes awareness and acceptance of
uncomfortable feelings and sensations rather than efforts
to avoid contact with such experiences.
Patients are encouraged to incorporate mindfulness into
their daily activities as well as to practice specific
mindfulness exercises.
 increase awareness of negative spirals, are combined
with aspects of cognitive behavioral training

45. Problem-solving therapy (PST)
aims to improve individuals’ problem-solving attitudes and
behaviors in order to decrease distress and improve quality
of life.
 Social problem solving is defined as a cognitive-
behavioral process that involves directing efforts to cope
with a problem toward changing the nature of the situation,
changing one’s reaction to the problem, or both.

46. Problem-solving therapy (PST)
According to social problem solving theory, one’s ability to
successfully solve problems is based on both problem
orientation and problem-solving style.
Problem orientation includes an individual’s beliefs,
attitudes, and emotional reactions to problems and their ability
to cope with these problems.
. These skills include: (a) defining a problem, (b) determining
alternative solutions, (c) decision making regarding different
solution strategies, and (d) implementing and evaluating a
particular solution strategy

47. •Light therapy (phototherapy) is
exposure to light that is brighter than
indoor light but not as bright as
direct sunlight. Do not
use ultraviolet light, full-spectrum
light, heat lamps, or tanning lamps
for light therapy.

48. •To treat seasonal affective disorder (SAD),
which is depression related to shorter days
and reduced sunlight exposure during the
fall and winter months. Most people with
SAD feel better after they use light therapy.
This may be because light therapy replaces
the lost sunlight exposure and resets the
body's internal clock
•Physical activity
•Exercise
•Release of endorphins
•With recommended intensity and frequency

49. What Is Electroconvulsive Therapy (ECT)?
•ECT is among the safest and most effective treatments available for depression.
With ECT, electrodes are placed on the patient's scalp and a finely controlled
electric current is applied while the patient is under general anesthesia. The current
causes a brief seizure in the brain. ECT is one of the fastest ways to relieve
symptoms in severely depressed or suicidal patients. It's also very effective for
patients who suffer from mania or a number of other mental illnesses.
•ECT is generally used when severe depression is unresponsive to other forms of
therapy. Or it might be used when patients pose a severe threat to themselves or
others and it is too dangerous to wait until medications take effect.

52. Pharmacological Treatment

53. Selective serotonin reuptake
inhibitor:
• fluoxetin[Prozac],
•citalopram(Cipralex)
•escitalopram(Cipram )
MOA:
selectively inhibit reuptake of serotonin
little affect on dopamine, H1 receptor,
alpha adrenergic receprors

54. Selective serotonin reuptake
inhibitor:
EFFECT:
atleast 2 weeks for action
max. effect upto 12 weeks
improved mood,
USES:
generalized anxiety disorder
depression
stress disorder

55. KINETICS:
•food little affect on absorption
•well absorbed orally
•half life 16 to 36 hours(for dose calculation )
•CYP 450 dependent enzyme
•Urine excretion except sertaline (fecal)…[dose adjustment]
ADVERSE EFFECT:
•Suicidal attempt in children
•Withdrawl symptoms
•Insomnia
•Nausea
•Drowsiness

56. Serotonin/nor epiniephrine
reuptake inhibitors:
• Venlafaxine (effexor)
•Desvenlafaxine (pristiq)
•Duloxetine (cymbalta)
MOA:
Inhibit reuptake of both serotonin and
nor epinephrine
For pts. Who not respond to SSRI
USES:
•For backache and muscle ache
•Depression

57. KINETICS:
•CYP450 inhibitors
•Half life 11 hours (van and desvan)
•Half life 12 hours (duloxetine)
•Metabolism: liver
•Excretion : urine
ADVERSE EFFECT:
•Nausea
•headache
•insomnia
•sedation
•increased BP
•Withdrawl symptoms

58. TRICYCLIC ANTIDEPRESSENTS:
•Amitriptyline
•Nortriptyline
•Imipramine
•Clomip[ramine
MOA:
Inhibit reuptake of NE and serotonin
Alternative of SSRI
Also blocks H1, alpha adrenergic &
muscarinic receptors

59. TRICYCLIC ANTIDEPRESSENTS:
EFFECT:
•4 to 8 weeks
USES:
•Moderate to severe depression
•Control bed wetting by children
•Insomnia
•Migraine

60. KINETICS:
•Well absorbed orally
•Distribution: rapid
•BA: low
•Metabolism: liver
•Excretion: urine
•Half life: 4 to 17 hours

61. ADVERSE EFFECTS:
•Muscarinic receptors:
•Blurred vision
•Xerostomia (dry mouth)
•Arrhythmias
•Constipation
•Alpha receptors:
•Hypotension
•Reflex tachycardia
•Dizziness
•H1 receptors:
•Sedation

62. MONOAMINE OXIDASE INHIBITORS:
MOA:
Inhibits MAO enzymes, escape degradation, increased
release of neurons in synaptic cleft, activate NE & serotonin
receptors
EFFECT:
•2 to 4 weeks
USES:
•Pts. Who do not respond to TCAs
•Strong anxiety
•Phobic states

63. KINETICS:
•Well absorbed orally
•Metabolism: liver
•Excretion: urine
ADVERSE EFFECT:
•Hypertension crises
•Drowsiness
•Dry mouth
•Blurred vision
•Drowsiness.

64. Refrences
• Lippncot
• Medscape
• Webmed
• International Society for Interpersonal Psychotherapy. Web
page http://www.interpersonalpsychotherapy.org/ •
Weissman MM. Recent non-medication trials of
interpersonal psychotherapy for depression. Int J
Neuropsychopharmacol. 2007 Feb;10(1):117-22. • Parker G.
What is the place of psychological treatments in mood
disorders? Int J Neuropsychopharmacol. 2007
Feb;10(1):137- 45. • Stuart S Robinson M. Interpersonal
Psychotherapy: A clinicans Guide. 2003 Arnold, London

65. Refrences
• https://www.omicsonline.org/.../major-depressive-disorder-
pathophysiology-and-clini...
• www.webmd.com/depression/features/stress-depression
• medical-dictionary.thefreedictionary.com/stress
• Ghosal, S., B.D. Hare, and R.S. Duman, Prefrontal cortex GABAergic deficits
and circuit dysfunction in the pathophysiology and treatment of chronic
stress and depression. Current opinion in behavioral sciences, 2017. 14: p.
1-8.
• Drevets, W.C., J.L. Price, and M.L. Furey, Brain structural and functional
abnormalities in mood disorders: implications for neurocircuitry models of
depression. Brain structure and function, 2008. 213(1-2): p. 93-118.
•
• www.who.int/occupational_health/topics/stressatwp/en/
• google search engine for images