Depression Depression. It’s not only a state of mind. The symptoms of depression Emotional Symptoms Include: Sadness Physical Symptoms Include: Vague aches and pains Headache Sleep disturbances Fatigue Back pain Significant change in appetite resulting in weight loss or gain Loss of interest or pleasure Overwhelmed Anxiety Diminished ability to think or concentrate, indecisiveness Excessive or inappropriate guilt Reference: Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition,Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489. Depression – the physical presentation In primary care, physical symptoms are often the chief complaint in depressed patients In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief compliant1 N = 1146 Primary care patients with major depression Reference: 1. Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335. Aches/pain – a physical symptom of significance Aches/Pain as common as anxiety among depressed patients 70 National Comorbidity Survey NIMH Epidemiology Study % of Depressed Patients 60 50 40 30 20 10 0 25% 55% 58% 38% 35% 37% 28% 17% Aches/Pain (Women) Aches/Pain (Men) Anxiety Disorder Anxiety Disorder (Women) (Men) Adapted from 1.Silverstein B. Am J Psychiatry. 1999;156(3):480-482. 2.Silverstein B. Am J Psychiatry. 2002;159(6):1051-1052. The importance of emotional and physical symptoms • 76% of compliant depressed patients with lingering symptoms of depression relapsed within 10 months1* 94% of depressed patients who experienced lingering symptoms had mild to moderate physical symptoms1 *Psychiatric inpatients and outpatients. Reference: 1. Adapted from: Paykel ES, et al. Psychol Med. 1995;25:1171-1180. Serotonin5HT and NorepinephrineNE in the brain Limbic System Prefrontal Cortex Raphe Nuclei (5-HT source) Locus Ceruleus (NE Source) Cooper JR, Bloom FE. The Biochemical Basis of Neuropharmacology. 1996. There are at least two sides to the neurotransmitter story Functional domains of Serotonin and Norepinephrine1-4 Serotonin (5-HT) Sex Appetite Aggression Depressed Mood Norepinephrine (NE) Concentration Interest Motivation Anxiety Vague Aches and pain Irritability Thought process • Both serotonin and norepinephrine mediate a broad spectrum of depressive symptoms References: 1. Adapted from: Stahl SM. In: Essential Psychopharmacology: Neuroscientific Basis and Practical Applications: 2nd ed. Cambridge University Press 2000. 2. Blier P, et al. J Psychiatry Neurosci. 2001;26(1):37-43. 3. Doraiswamy PM. J Clin Psychiatry. 2001;62(suppl 12):30-35. 4. Verma S, et al. Int Rev Psychiatry. 2000;12:103-114. The neurotransmitter pathway story It’s not all in your head • Dysregulation of Serotonin (5HT) and Norepinephrine (NE) in the brain are strongly associated with depression • Dysregulation of 5HT and NE in the spinal cord may explain an increased pain perception among depressed patients1-3 • Imbalances of 5HT and NE may explain the presence of both emotional and physical symptoms of depression. Adapted from References: 1. Stahl SM. J. Clin Psych. 2002;63:203-220. 2. Verma S, et al. Int Rev Psychiatry. 2000;12:103-114. Descending Pathway Descending Pathway Ascending Pathway Ascending Pathway 3. Blier P, et al. J Psychiatry Neurosci. 2001;26(1):37-43. CLASSIFICATION • The three subgroups of depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, • Fourth Edition (DSM-IV) are: 1. Major depression 2. Dysthymia 3. Atypical depression or depression not otherwise specified (NOS) • These need to be differentiated from grief and bereavement, which are normal responses to a loss. • Seasonal affective disorder is not a separate mood disorder it is classified as a specifier to major depression. Major depression • The DSM-IV criteria for major depression require that at least 5 of following 9 symptoms are present during the same period • 1. Depressed mood most of the day • particularly in the morning • 2. Markedly diminished interest or pleasure in almost all activities nearly every day (anhedonia) • can be indicated by subjective account or observations by significant others Major depression Cont….. • 3. Significant weight loss or gain • 4. Insomnia or hypersomnia • 5. Psychomotor agitation or retardation • 6. Fatigue or loss of energy • 7. Feelings of worthlessness or guilt • 8. Impaired concentration, indecisiveness • 9. Recurring thoughts of death or suicide Major Depression Cont….. • One of the symptoms must be either depressed mood or loss of interest • Symptoms should be present daily or for most of the day, or nearly daily for at least two weeks • The symptoms must cause clinically significant distress or impairment in functioning • not due to the direct effects of substance (eg,drug abuse or medications) or a medical condition (eg, hypothyroidism) • do not occur within 2 months of the loss of a loved one (unless associated with pathologic grief,) Minor depression • Minor" depression, sometimes also called "atypical" depression, • but deserves particular mention because of frequency with which it occurs in the primary care setting • Similar to major depression, symptoms should be present daily or for most of the day, or nearly daily for at least two weeks • Rather than having at least 5 symptoms, however,pts have only 2-4 depressive symptoms • Minor Depression • Often characterized by hypersomnia & weight gain • In contrast to the insomnia & weight loss assoc with major depression, • Many pts with frequent complaints who have no medical explanation for their symptoms have minor depression • Furthermore, the term "minor" should not leave the impression that the illness is not important • Dysthymia • more chronic, low intensity mood disorder • By definition, symp must be present > 2 yrs consecutively • It is charac by anhedonia, low self-esteem, & low energy • It may have a more psychologic than biologic etiology • tends to respond to Rx & psychotherapy equally • Long-term psychotic is frequently able to bring about lasting change in dysthymic individual • Grief & bereavement • normal responses to the loss of close relationship • Depression, suicide, anxiety, & complicated grief are most common adverse psychological sequelae of loss • Rates of depression during the first year after loss of a spouse are 1535% • figures that are 4-9 times higher than rate of general population • The risk of suicide also appears to be elevated among individuals who have lost a spouse • particularly in older men & in first year after a death • Complicated or traumatic grief • syndrome in which indiv does not return to the level of function & well-being at which he or she lived before loss • It involves persistence of reactions that are normal in immediate period after a loss • eg, difficulty accepting the death • denial of the death • absence of grief • Searching • preoccupation with thoughts of the deceased • avoidance of reminders of the deceased • auditory & visual hallucinations of the person who has died • Normal grief reactions are resolved in 94% of indiv by 13 months after a loss • Seasonal affective disorder • The criteria for adding the seasonal pattern specifier to dx of major depression include the following • 1. Regular temporal relationship between onset of major depressive episodes & particular time of year • unrelated to obvious season-related psychosocial stressors • 2. Full remissions (or a change from depression to mania or hypomania) also occur at a charac time of the year • 3.Two major depressive episodes meeting the first two criteria in last 2 years & no nonseasonal episodes in the same period • 4. Seasonal major depressive episodes substantially outnumber the nonseasonal episodes over individuals lifetime • EPIDEMIOLOGY • Approximately 10-40% of pts in the primary care setting have significant depressive symptoms • but < 50% meet DSM-IV criteria for major depressive disorder • The point prevalence for major depressive disorder in Western industrialized nations is 2.3-3.2% for men & 4.5- 9.3% for women • Lifetime risk for major depressive disorder is 7-12% for men & 20-25% for women • A 2005 survey of over 43,000 US adults aged 18 and older found the 12 month prevalence of major depressive disorder to be 5.3% • lifetime incidence 13.2% RISK FACTORS • The primary risk factors for major depressive disorder include: • Female gender • History of depressive illness in first degree relatives • Prior episodes of major depression • The explanation for the female preponderance is not entirely clear • Contributing factors may include: • high incidence of postpartum depression • social factors (eg, history of childhood abuse • low self-esteem) • gender differences in metabolism of noradrenergic & serotonergic neurotransmitters Risk Factors • Contd… • Both animal & human studies suggest that early stressors (eg, childhood sexual abuse) cause long-term dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis similar to that seen in depressed pts • The HPA axis in women may be more susceptible to stress-induced dysregulation than in men • contributing to an ↑vulnerability to depression in adult women • Other risk factors: • more remote family history of depressive disorder • lack of social supports • significant stressful life events • current alcohol and substance abuse • Biologic Basis of Depression • Severe symp of major depression generally require some biologic intervention, either with antidepressants or ECT • There is currently no biologic marker for depression, although the following may be seen in depressed individuals: • Early REM latency (dreaming as soon as falling asleep) • Early morning awakening • Poor appetite • Weight loss • Pseudodementia • ↓ cognitive performance that resolves with successful treatment of depressive symptom •Biologic Basis of Depression • Depression is assoc with physical changes in the brain • A meta-analysis of MRI studies concluded that hippocampal volume, measured at a single point in time, is ↓ approx 10% in pts with unipolar depression • it is unclear whether this is an effect on the brain because of repeated bouts of depression Conditions assoc with depression • A number of medical conditions may present with depression, including: • Cancer . Stroke . Diabetes . Dementia • Hypothyroidism • Chronic fatigue syndrome • Fibromyalgia • Systemic lupus erythematosus • Coronary heart disease • Corticosteroid use • Anxiety and panic disorders • A causal link has not been established in all circumstances, although depression may resolve with treatment of underlying medical conditions Treatment • Pharmacotherapy- SSRI, TCA • Electro convulsive therapy • Psychotherapy –Psychoanalytic, interpersonal, family,behavorial and cognitive.
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