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Understanding depresssion
This document provides an overview of depression, including its signs and symptoms, classification, diagnosis, and treatment. It defines depression as a common psychiatric disorder characterized by depressed mood and loss of interest. It discusses the history of understanding depression and classifies types according to the DSM-IV, including major depressive disorder, dysthymia, and bipolar disorder. The document also explores biological and psychological theories of causation and outlines methods of diagnosis and treatment options like psychotherapy, pharmacotherapy, electroconvulsive therapy, and antidepressants.
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Understanding depresssion
- 1. Understanding Depression Madan Baral Second Semester,B. Pharmacy School of Health and Allied Sciences Pokhara University, Dhungepatan, Lekhnath-12, Kaski , Nepal
- 2. Objectives •Understand Signs andSymptoms •Differentiate between types of depression •Understand Causation •Understand Diagnosis Methods •Understand Treatment
- 3. WHAT IS DEPRESSION? •common potentially debilitating psychiatric disorder characterized by depressed mood, loss of interest or pleasure, feelings of guilt, disturbed sleep or appetite, low and poor concentration.
- 4. HISTORY •Ancient Egyptians wroteabout depression more than 3000 years ago •Ancient Greek thought depression as the cause of excess of bile •Hippocrates, first person to throughly describe the condition as a somatic illness and coin the term “melancholia” •Ludwig Van Beethoven, Charles Dickens, Winston Churchill, Abraham Lincoln and Ernest Hemingway some famous people said to have suffered from depression
- 5. CLASSIFICATION ON THEBASIS DSM-IV • Depression classified with its subtypes under Mood Disorder by American Psychiatric Association published in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) ✦ Mood Disorder A. Depressive Disorder 1. Major Depressive Disorder, Single Episode 2. Major Depressive Disorder, Recurrent 3. Dysthymia Disorder 4. Depressive Disorder Not Otherwise Mentioned – Bipolar Disorder » Bipolar Disorder, Single Episode » Bipolar Disorder, Recurrent A.Cyclothymic Disorder 1. Bipolar Disorder Not Otherwise Specified 1. Secondary Mood Disorder due to Non-psychiatric Medical Condition 2. Substance- Induced Mood Disorder 3.Mood Disorder Not Otherwise Specified
- 6. Facts and Statistics •Peopleof all ages, backgrounds, lifestyles, and nationalities suffer from major depression, with a few exceptions. •Up to 20% of people experience symptoms of depression. •The average age of first onset of major depression is 25-29 •Ranked as 4th highest public concern according to WHO and assumed to be 2nd by 2020
- 7. Major Depressive Disorder •Alsocalled clinical depression or unipolar depression •The most prevalent depressive disorder •Some 340 million persons worldwide meet the criteria for clinical depression
- 8. Symptoms •The symptoms ofdepression are: Emotional Symptoms: Physical Symptoms: Depressed mood Change in body weight and appetite Loss of interest or pleasure Disturbances of sleep and other Circadian rhythm Anxiety Fatigue Diminished ability to think or concentrate, or indecisiveness Psychomotor agitation or retardation Feeling of excessive or inappropriate guilt Unexplained body aches Recurrent thoughts of deaths and suicidal Headache
- 9. Types •Classified further onthe basis of occurrence a. Single Episode b. Recurrent •Single episode - occurs only once and meets all the diagnostic symptoms of major depression •If untreated, 85% of persons who have one episode of depression will have another episode within 10 years •Recurrent-2 major depression episodes, separated by at least a 2 month period •Median number of depressive episodes per person is 4 •25% have 6 or more episodes
- 10. Dysthymia • chronic “low-grade”or mild depression • symptoms not as strong as the symptoms of major depression • Diagnostic Symptoms : A. Depressed/irritable mood B. Presence of two of the following: • Appetite disturbance • Sleep disturbance • Low energy/fatigue • Poor concentration of difficulties making decision • Feelings of hopelessness C. Present for two year period (one year in children and adolescents)
- 11. Bipolar Disorder •manic-depressive disorder •presenceof one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or more depressive episodes Characteristic Episodes – Depressive Episode :disturbances in sleep and appetite, fatigue, –Manic Episode : elevated, irritable mood state ,grandiosity –Hypomanic Episode : milder mania
- 12. Etiology and Pathophysiology A.BiologicalTheories 1.Genetics 2.Biochemical Theories a. Monoamine Hypothesis b. Neurotransmitter Dysregulation Hypothesis c. Neuroendocrine Findings B.Psychological Theories 1. Psychoanalytical Factors A. Learning Theories 1. Object Loss theory 2. Cognitive Theory a. Social Theory a.Family Based c.Society Based
- 13. Genetics Family Studies • firstdegree relatives of (children,siblings,parents) of depressed individuals are 1.5 to 3 times more likely to have depression compared to general population Twin Studies •concordance rate of monozygotic twins ranges from 54-65% while in dizygotic twins in only 15-24
- 14. Biochemical Theories • MonoamineHypothesis • Neurotransmitter Dysregulation Hypothesis • Neuroendocrine Findings
- 15. Monoamine Hypothesis • Depletionin the levels of serotonin, norepinephrine, and/or dopamine in the CNS. • Norepinephrine regarded as the component in the mobilization of the body toy deal with stressful event. • Serotonin System- mood and arousal thinking,energy, libido, cognition,appetite,aggression and circadian rhythm. • Dopamine System -human mood and behavior. • Decreased level of biogenic amines in synaptic cleft inhibits the transmission of impulses from one neuron to another causing a failure of the cells to fire or charge. • Pathophysiology supported by the mechanism of action of antidepressants and autopsy of depressed person
- 18. Monoamine Hypothesis Limitations • Delayedonset of drug • Not all the depressed patient have decreased synaptic concentration of of biogenic amines • antidepressant can work via other mechanisms which do not involve reactive increased in synaptic neuro-transmitter concentration (eg. can block corticotropin releasing factor)
- 19. Neurotransmitter Dysregulation Hypothesis •Explainsdepression as the cause of failure of regulation of neurotransmission system Factors - Impairment in homeostasis or regulation - Disruption of normal periodicity ( Circadian rhythm ) - less selective response to stimuli
- 20. Neuroendocrine Findings •Neuroendocrine abnormalitiesmay develop depression •Abnormal thyroid function test including low triiodothronine(T3) and thyroxine(T4) •Abnormal response to TRH(thyroid releasing hormone) consisting or blunted or exaggerated thyroid stimulating hormone (TSH) •Clinical hypoparathyroidism •HPA axis influence manifestation of depression •Concentrations of CRF is elevated during depressive episodes •Decreased hippocampus
- 22. Psychological Theories • PsychoanalyticalTheory • Learning Theories • Object Loss theory • Cognitive Theory
- 23. Psychoanalytical Theory •Sigmund Freudfeatures of melancholia – a profoundly painful dejection – loss of interest in world – loss of capacity to love •Interpretation of melancholia – actual loss of loved one or emotional rejection –feelings of self-hatred develop and worthlessness and losses his or her self-esteem
- 24. Learning Theory •Seligman’s “learnedhelplessness” experiment on dogs •Helplessness in human with numerous traumatic situations either real or perceived •Seligman’s interpretation of depression –Learned helplessness predisposes depression by imposing a feeling of lack of control and hopelessness over their life situation and failures
- 25. Object Loss Theory(Attachment Theory) •Attachment theory by John Bowlby, English psychiatrist, •Relationship between depressive disorder in adulthood and the quality of the earlier bond between the infant and their adult caregiver. •The experiences of early loss, separation and rejection by the parent or caregiver •Absence of security and emotional absence
- 26. Cognitive Theory • Put-forthby Aaron Beck •3 cognitive distortion reality •Negative expectation – Environment – Self – Future •Contrary view
- 27. Social Theory •Family –Problems withfamily –Family stress •Social –Substantial life events –Social isolation
- 28. Diagnosis •Clinical Assessment •Behavioral RatingScales •DSM-IV Criteria and IDS-10 Criteria
- 29. Clinical Assessment •By Clinician,trainedmedical practitioner, psychiatrist or psychologist •Mental state assessment – appearance, behavior speech, mood, memory, and intellectual function •Physical Examination – palpitation in neck, laboratory tests ( TSH, thyroxine, testosterone level) •Other bodily changes
- 30. Behavioral Rating Scales •Setof questionnaire for depression assessment •Uses – Screening mental state – Quantifying target symptoms – Determine treatment efficacy •Clinically preferred – Hamilton Rating Scales for Depression (HRS-D) – Montgomery-Asberg Rating Depression Rating Scale –National Institute of Mental Health Diagnostic Interview Schedule (DIS)
- 31. DSM-IV Criteria andICD-10 Criteria •DSM-IV – American Psychiatric Association's revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) •ICD-10 – World Health Organization's International Statistical Classification of Diseases and Related Health (ICD-10)
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- 33. Psychotherapy •Interpersonal therapy: –assist insolving relationship problems that cause depression •Cognitive-behavioral therapy: – changes the pessimistic ideas and unrealistic expectations –develop positive life goals, and a more positive self-assessment
- 34. Electroconvulsive Therapy How isit done? •Pulses of electricity are sent through the brain via two electrodes •Painless procedure •A person is put to sleep with general anesthesia •Muscle relaxers are used to prevent any injury from the procedure Advantages •Quicker effect than antidepressant therapy and thus may be the treatment of choice in several emergency occasions
- 35. Pharmacotherapy • Use ofantidepressants • Selective serotonin-reuptake inhibitors (SSRIs) like fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram • Tricyclic Antidepressants(TCAs) like amitriptyline, • Monoamine oxidase inhibitors (MAOIs)
- 36. References • Young Kimble(2000) et al., Applied Therapeutics: The Clinical Use of Drugs (7th Ed.), Lipincott Williams & Wilkins, Baltimore, pp 77-77-21. • Kasper et al., Harrison’s Principle of Internal Medicine (16th Ed.), McGraw and Hill Companies, New Delhi, pp 2553-2557. • Boyd Nihart (1998) Psychiatric Nursing Contemporary Practice, Lipincott Williams and Wilkins, New York, pp 438-472. • Basavantha BT (2007) Psychiatric Mental Health Nursing (1st Ed.) Jaypee Brothers Medical Publishers Ltd New Delhi, pp 494-521. • URL-1: http:// www.who.int/mental_health/management/depression/definition/en/ (Accessed on October 1, 2010) • URL-2: http://en.wikipedia.org/wiki/Major_depressive_disorder#Symptoms_and_signs • URL-3: http://www.helpguide.org/mental/depression_signs_types_diagnosis_treatment.
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