Depressive Disorder

Prepared by -Dr Hilina Tewabe(PGY 1)

Moderator –Dr Barkot Milkias (Assistant
professor of Psychiatry)
May 2021
Outlines
• Introduction
• Epidemiology
• Clinical presentations
• Ethiology
• Diagnosis and Classification of depressive
disorders
Introduction
• Mood refers to a sustained emotion that colors the
way we view life.
• Disorders of mood are often called affective
disorders, since affect is the external display of
mood.
• Depression and mania are often seen as opposite ends
of an affective or mood spectrum.
• Disorder that looks more like the expression of a
continuum than a useful category.
Introduction cont,

Depression has a range of meaning

from a description of
• normal unhappiness through persistent and pervasive
ways of feeling and thinking to psychosis.
• is a complex diagnostic construct in which the
essential ingredients are a depressed mood and a loss
of interest
 Epidemiology

• The lifetime prevalence estimates average 11.1

in low and 14.6 in high-income countries

• whereas the 12-month prevalence rates

average 5.5 in high and 5.9 in low income
countries.
• The lifetime rates of major depressive
disorder in childhood range from about 0.6 to
4.8 percent.

• prevalence of major depressive disorder

increased significantly across adolescence,
with markedly greater increases among
females than among males.
Correlates of mood disorders

1. Gender

• approximately two fold more common among

women than men.

• This gender difference begins in early adulthood,

is most pronounced in people between the ages
of 30 and 45, and also persists in the elderly.
Aside from biological–hormonal differences) that show
that female gender per se means

• increased vulnerability for depression increased stress

sensitivity,
• maladaptive coping strategies and multiple social
roles.
• substance use disorders that can mask depressive
symptoms (more frequently seen in men) have been
suggested
Age

• Depressive disorders show much higher lifetime

prevalence among people younger than 45 years.

• Social stressors appear to place younger individuals at a

greater risk for depression than elderly ones.

• On the other hand, isolation, loss of interpersonal

contacts, medical disorders, and disability play a more
important role in the development of depression in later
life.
Race and ethinicity

• Rates of mood disorders are lower in blacks and

Hispanic than in whites.

• Because of their increased exposure to psychosocial

stress and other risk factors for mood disorders, the
lower rates in these ethnic subgroups is paradoxical.
Marital status

• Major depressive disorder and bipolar illness are

most frequent among divorced, separated, or
widowed individuals.

• Single women have lower rates of depression than

married women do, but the opposite is true for men.
Socio economic

Individuals with lower socioeconomic status

have

• a lower level of educational,

• lower income
• poorer living conditions
• higher rate of unemployment
• homelessness.
Residence

• major depression was more frequent in urban

residents than in their rural counterparts.

• As urban communities are more stressful than rural

ones.

• respondents living in rural areas had approximately

40 percent lower odds of 1-year comorbidity of three
or more mental disorders than did those living in
urban areas.
Social stressors

• chronic stressors (e.g.unemployment, difficult

marriage) play a more important

• Accumulation of stressful negative life events is the

strongest predisposing factor.

• Acute, positive life events (that are quite rare in

Western communities) can also precipitate either
major depression or mania in vulnerable individuals.
Social support

• living alone, having low socioeconomic status,

and being unemployed are significant risk
factors for mood disorders.

• Poor social support is related to onset, relapse,

and recurrence of depression,
Comorbid
Disorders
• alcohol abuse or dependence
• panic disorder
• OCD
• Social anxiety disorder.

In both unipolar and bipolar disorder, men more

frequently present with substance use disorders,
whereas women more frequently present with comorbid
anxiety and eating disorders
Clinical presentation
• A depressed mood and a loss of interest or pleasure are the
key symptoms of depression.

Depressed mood
• Patients may say that they feel blue, hopeless, in the
dumps, or worthless, Emptiness ,Unhappiness and Distress

• For a patient, the depressed mood often has a distinct

quality that differentiates it from the normal emotion of
sadness or grief.
Clinical featurs con..

• Even if it has been triggered by a life event, it

evolves autonomously, dissociated from that
event, and resists being changed through
reasoning or encouragement

• It is associated with cognitive and somatic

symptoms (guilt, self-reproach, suicidal
thoughts and a variety of unpleasant and painful
bodily sensations)
Clinical featurs con..

Anhedonia— Loss of Interest

• They are unable to draw pleasure from previously

enjoyable activities.
• In severe cases they disregard and abandon most of
the things they valued in life.
• retain insight of their own inability to experience and
express normal emotions and this intensifies their
suffering
Clinical featurs con..

• Patients often describe the symptom of depression

as one of agonizing emotional pain.

• Alternately they perceive it as a physical illness in

which they feel exhausted and unmotivated.

• Others report feeling little, being unable to cry.

And being unable to express emotions, even their
own psychic pain.
Clinical featurs con..

• The intensity and the depth of the pain become

so unbearable that often the death wish
provides a comforting remedy.
Vegetative states
They are manifested as profound disturbances in
• eating
• in sleep
• in sexual function
• loss of vitality
• motivation, energy and capacity to respond positively to
pleasant events.
• diffuse pains, and complaints of fatigue and physical
discomfort are reported.
Somatic syndrome

Present if more than four of the following features are

present
• Anhedonia
• Loss of reactivity (loss of emotional reactivity to
• normally pleasurable surroundings and events)
• Early waking ( > 2 hours early)
• Psychomotor retardation or agitation
• Marked loss of appetite
• Weight loss > 5% of body mass in one month
• Loss of libido
Mental State examination.

The classic presentation of a depressed patient is a person with a

• stooped posture,
• decreased movement
• downward averted gaze.

Peculiar triangle-shaped fold in the nasal corner of the upper

eyelid- Veraguth’s fold

Have range of behaviours ranging from persons with no

observable symptoms to the catatonically depressed patient.
Psychomotor disturbance
Agitation
• usually accompanied by anxiety, irritability, restlessness, hand
wringing and hair pulling.

Retardation

• slowing of bodily movements

• mask-like facial expression
• lengthening of reaction time to stimuli,
• increased speech paucity
• as an inability to move or to be mentally and emotionally activated
(stupor),
Speech
• Many depressed patients have a decreased rate
and volume of speech;
• They respond to questions with single words
and exhibit delayed responses to questions.
• Have negative views of the world and
themselves.
Mood, Affect, and Feelings
• Depression is the key symptom in which 50% deny
feeling & don’t appear to be particularly depressed.
• Brought by attendants b/c of social withdrawal &
generally decreased activity.
• Alexithymia, blunted or restricted affect and may be
irritable
Thought

• Their thought content often includes non

delusional ruminations about loss, guilt,
suicide, and death.

• About 10 percent of all depressed patients have

marked symptoms of a thought disorder, usually
thought blocking and profound poverty of content.
Perceptions
Depressed patients may complain of either delusions or hallucinations.
Delusions and hallucinations that are consistent with a depressed mood
are said to be
mood-congruent
include
• guilt and sinfulness,
• worthlessness,
• poverty,
• Failure
• persecution,
• and terminal somatic illnesses
Mood-incongruent delusions or hallucinations

Includes
• grandiose themes of exaggerated power,
knowledge, and worth.
Judgment, Insight and Reliability
• Depressed patients hyperbolic; they overemphasize their
symptoms, their disorder & their life problems.
• It is difficult to convince such pts. that improvement is
possible.
• overemphasize the bad and minimize the good.

• Psychiatrists should not view patients misinformation as

an intentional fabrication
 MSE cont……….
Sensorium and Cognition

Orientation
• Most depressed pts. are oriented to PPT although
some may not have sufficient energy or interest to
answer questions about these subjects during an
interview.

32
Cognitive disturbance

• Difficulty in concentrating
• negative thoughts
• low self-esteem and self confidence,
• hopelessness
• sense of worthlessness and sinfulness,
• negative outlook on the world
• suicidal thoughts.
Memory – have memory loss and disturbance.
 MSE cont……….
Impulse Control
• About 10-15 % of all depressed patients commit suicide,
and about two-thirds have suicidal ideation.

• Depressed pts. with psychotic features can be homicidal

as a result of their delusional systems, but the most
severely depressed pts. often lack the motivation/energy
to act in an impulsive/violent way.

• At increased risk of suicide as they begin to

improve/regain the energy needed to plan/carry out a
suicide-paradoxical suicide.
 Etiology
 Genetic
 Neurobiological factors ;

– neurotransmitters
– Neuroendocrine abnormalities
– structural & functional brain abnormalities
 Psychosocial factors ;

– Social support
– Cognitive theories

– life events & interpersonal difficulties 35

 Etiology cont………….

Genetic Factors
 Family Studies
• Family data indicate that if one parent has a mood disorder,
a child will have a risk of b/n 10-25% for mood disorder.
• If both parents are affected, this risk roughly doubles.
• The more members of the family affected & more severe
illness in the family and the greater the risk is to a child.
• The risk is greater if the affected family members are first-
degree relatives.
36
 Etiology cont………….

Twin Studies

• Twin studies provide the most powerful approach to separating

genetic from environmental factors, or “nature” from “nurture.”

• The twin data provide compelling evidence that genes explain

50-70% of the etiology of mood disorders.

• Environment or other nonheritable factors must explain the

remainder
37
 Etiology cont………….

• It is a predisposition or susceptibility to disease that is

inherited.

• Considering unipolar & bipolar disorders together, these

studies find concordance rate for mood disorder in the MZ

twins of 70-90% compared with the same-sex DZ twins of 16

-35%.

• This is the most compelling data for the role of genetic factors

in mood disorders.
38
 Etiology cont………….

 Adoption Studies.
• Twofold increase in unipolar disorder in the biological relatives
of bipolar probands.
• Similarly, in a Danish sample, a threefold increase in the rate
of unipolar disorder and a six fold increase in the rate of
completed suicide in the biological relatives of affectively ill
probands were reported.

• Other studies, however, have been less convincing and

have found no difference in the rates of mood disorders.
39
Neurobiology of depression
• Researchers examined the brains, bodies, and behaviors of
depressed patients in the search for clues of the underlying
pathology of depression.

• This search is complicated by the fact that most experts on

depression agree what we call major depressive disorder is not
a single disease, but rather a collection of disorders with
overlapping phenomenology but different etiologies and
pathologies.
Depression as a Disorder of Homeostasis

Depression and the Hypothalamic–Pituitary–

Adrenal Axis.
• on average, depressed patients have an overactive
hypothalamic–pituitary–adrenal (HPA) axis.
.
• Compared with controls, depressed patients have increased
cortisol levels over 24 hours.

• This hypercortisolemia is due to increased corticotropin-

releasing hormone (CRH) from the hypothalamus, along with
decreased feedback inhibition.
• Elevated HPA activity is a hallmark of the mammalian stress
responses.
• Hypercortisolema in depression suggests one or more of the
following central disturbances:

1. decreased inhibitory serotonin tone

2. increased drive from norepinephrine, acetylcholine (ACh), or CRH; or
3. decreased feedback inhibition from the hippocampus.
• early trauma is associated with increased HPA activity accompanied by
structural changes (i.e., atrophy or decreased volume) in the cerebral
cortex.
THYROID AXIS ACTIVITY

– 5-10 % of people evaluated for depression have previously

undetected thyroid dysfunction, as reflected by an
• Elevated basal TSH level or
• An increased TSH response to a 500-mg infusion of the
hypothalamic neuropeptide TRH
– Often associated with elevated antithyroid antibody levels &
unless corrected with hormone replacement therapy, can
compromise response to Rx
• An even larger subgroup of depressed pts (..20-30%)
shows a blunted TSH response to TRH challenge.

• A blunted TSH response is evidence of an increased

risk of relapse despite preventive antidepressant
therapy.

• Unlike DST blunted TSH response to TRH does not

usually normalize with effective treatment
GROWTH HORMONE

• Secreted from the anterior pituitary after stimulation by NE &

dopamine

• Secretion is inhibited by somatostatin, a hypothalamic

neuropeptide, & CRH.

• Decreased CSF somatostatin levels have been reported in

depression, and increased levels have been observed in mania.

PROLACTIN

• Released from the pituitary by serotonin stimulation & inhibited

by dopamine.
• Most studies have not found significant abnormalities of basal or
circadian prolactin secretion in depression, although a blunted
prolactin response to various serotonin agonists has been
described.
• This response is uncommon among premenopausal women,
suggesting that estrogen has a moderating effect.
Alterations of Sleep Neurophysiology.

Depression is associated with

– A premature loss of deep (slow-wave) sleep
– An increase in nocturnal arousal - is reflected by

(1) Increase in nocturnal awakenings

(2) Reduction in total sleep time
(3) Increased phasic rapid eye movement (REM) sleep
(4) Increased core body temperature
Reduced REM latency

• The combination of increased REM drive & decreased slow-

wave sleep results in a significant reduction in the first period of
NREM sleep .
• REM latency and deficits of slow-wave sleep typically persist
after recovery of a depressive episode.
• Blunted secretion of GH after sleep onset is associated with
decreased slow-wave sleep & shows similar state-independent
or trait-like behavior.
• The combination of reduced REM latency, increased REM

density, & decreased sleep maintenance identifies approximately

40% of depressed outpatients & 80% of depressed inpatients.

• False-negative in younger, hypersomnolent patients, who may

actually experience an increase in slow-wave sleep during episodes

of depression.
Biogenic amines

 Of the biogenic amines, norepinephrine & serotonin are the two

neurotransmitters most implicated in the pathophysiology of mood
disorders.
NOREPINEPHRINE.
– Down regulation or decreased sensitivity of β-adrenergic receptors & clinical
antidepressant responses
– Presynaptic β2-receptors activation results
• in a decrease of the amount of norepinephrine released
• Also located on serotonergic neurons & regulate the amount of serotonin
released
 Venlafaxine (Effexor) antidepressant drugs with noradrenergic effects
SEROTONIN
– With the huge effect SSRIs--fluoxetine (Prozac)
– Most commonly associated with depression
– Depletion of serotonin may precipitate depression
– Some pts with suicidal impulses have CSF
concentrations of serotonin metabolites & low
concentrations of serotonin uptake sites on platelets.
DOPAMINE

– Dopamine activity may be reduced in depression &

increased in mania

– Drugs & diseases that reduce dopamine

concentrations— Reserpine (Serpasil) & Parkinson’s

disease are associated with depressive symptoms.

– Drugs that increase dopamine concentrations--tyrosine,

amphetamine, & bupropion (Wellbutrin), reduce the

symptoms of depression.

– Mesolimbic dopamine pathway may be dysfunctional in

depression

– Dopamine D1 receptor may be hypoactive in depression

Other Neurotransmitter Disturbances
– Acetylcholine (ACh) is found in neurons that are distributed
diffusely throughout the cerebral cortex

– Cholinergic neurons have reciprocal or interactive relationships

with all three monoamine systems

– Abnormal levels of choline--precursor to ACh, have been found at

autopsy in the brains of some depressed pts, perhaps reflecting
abnormalities in cell phospholipid composition.
– Cholinergic agonist produce lethargy, anergia, &

psychomotor retardation in healthy subjects, can exacerbate

symptoms in depression

– Cholinergic agonist induce changes in HPA activity and sleep

that mimic those associated with severe depression

– Increase in sensitivity to cholinergic agonists --- depression

γ-Amino butyric acid (GABA)
– Has an inhibitory effect on ascending monoamine pathways,
particularly the mesocortical & mesolimbic systems
– Reductions of GABA have been observed in plasma, CSF, and
brain GABA levels in depression
– Chronic stress can reduce and eventually can deplete GABA levels
– GABA receptors are upregulated by antidepressants

– Some GABAergic medications have weak antidepressant effects

 Amino acids glutamate & glycine

– Are the major excitatory & inhibitory neurotransmitters

in the CNS
– Glutamate & glycine bind to sites associated with the N-
methyl-D-aspartate (NMDA) receptor.
– Excess of glutamatergic stimulation can cause neurotoxic
effects
– High concentration of NMDA receptors exists in the

hippocampus.

– Glutamate, thus, may work in conjunction with

hypercortisolemia to mediate the deleterious neurocognitive

effects of severe recurrent depression.

– Drugs that antagonize NMDA receptors have

antidepressant effects.
Immunological Disturbance.

• Decreased lymphocyte proliferation in response to mitogens &

other forms of impaired cellular immunity.
• These lymphocytes produce neuromodulators, such as
corticotropin-releasing factor (CRF), and cytokines, peptides
known as interleukins.
• There appears to be an association with clinical severity,
hypercortisolism, and immune dysfunction, and the cytokine
interleukin-1 may induce gene activity for glucocorticoid synthesis.
 Etiology cont……..

Structural and Functional Brain Imaging.

– The most consistent abnormality observed in the
depressive disorders is increased frequency of
abnormal hyperintensities in subcortical regions such
as ;Periventricular regions
Basal ganglia
Thalamus

60
 Etiology cont……..

• hyperintensities appear to reflect the deleterious

neurodegenerative effects of recurrent affective episodes.

• Ventricular enlargement, cortical atrophy & sulcal widening

• Reduced hippocampal or caudate nucleus volumes, or both,

suggesting more focal defects in relevant neurobehavioral systems.

• Diffuse & focal areas of atrophy have been associated with

increased illness severity, bipolarity & increased cortisol levels.

61
 Etiology cont……..

• positron emission tomography (PET) finding in

depression shows decreased anterior brain metabolism,
which is generally more pronounced on the left side.

• Depression may be associated with a relative increase in

nondominant hemispheric activity

• Reversal of hypofrontality occurs after shifts from

depression into hypomania

62
• Reduced cerebral blood flow or metabolism, or both, in
the dopaminergically innervated tracts of the
mesocortical & mesolimbic systems in depression.
• Antidepressants at least partially normalize these
changes.
• Increased glucose metabolism has been observed in several
limbic regions, particularly among patient with relatively severe
recurrent depression & a family history of mood disorder.
• . 63
 Etiology cont……..

Neuroanatomical Considerations

• Modern affective neuroscience focuses on the importance of

four brain regions in the regulation of normal emotions:

– Prefrontal cortex (PFC)

– Anterior cingulate

– Hippocampus

– Amygdala
64
 Etiology cont……..

PFC

• PFC is viewed as the structure that holds

representations of goals & appropriate
responses to obtain these goals

65
 Etiology cont……..

• Evidence indicates some hemispherical specialization in

PFC function.

– Left sided activation of regions of the PFC is more involved in

goal-directed or appetitive behaviors,

– Regions of the right PFC are implicated in avoidance behaviors

& inhibition of appetitive pursuits.

• Subregions in the PFC appear to localize representations

of behaviors related to reward & punishment. 66

 Etiology cont……..

ACC

• involved in attention, motivation, and environmental

exploration and appears to help integrate attention and
emotional inputs.
• Activation of the ACC may facilitate control of emotional
arousal, particularly when attainment encountering novel
problems.

67
 Etiology cont……..

Hippocampus
• Most clearly involved in various forms of learning &
memory, including fear conditioning, as well as
inhibitory regulation of the HPA axis activity.
• Emotional or contextual learning appears to involve
a direct connection between the hippocampus and the

amygdala.

68
 Etiology cont……..

Amygdala
• Crucial way station for processing novel stimuli of
emotional significance and coordinating or organizing
cortical responses.
• Located just above the hippocampi bilaterally, the
amygdala has long been viewed as the heart of the limbic
system.
• Most research has focused on the role of the amygdala in
responding to fearful or painful stimuli. 69
2 theories

Neurogenesis Hypotheses-
• brain abnormalities leading to depression are the
result of abnormalities in development such that there
is a deficit in the number of newborn neurons in the
brain.
• Stress can cause increased activity in the HPA axis,
which results in increased glucocorticoid production.
Glucocorticoids are known to decrease neurogenesis.
Neuroplasticity Hypotheses.
• atrophy of already developed neurons causes
depression.
• chronic stress can increase glucocorticoid levels,
which can cause atrophy. It can also decrease the
expression of brain-derived neurotrophic growth
factor (BDNF), which is essential for the survival,
growth, and differentiation of neurons in the brain.
 Etiology cont……..

Psychosocial Factors
Life Events and Environmental Stress.

• Stressful life events more often precede first, rather

than subsequent, episodes of mood disorders for
both patients with MDD and bipolar I disorder.
• The stress accompanying the first episode results in
long-lasting changes in the brain’s biology.

72
 Etiology cont……..

• These long-lasting changes may alter the functional states of

various neurotransmitter and intraneuronal signaling
systems, changes that may even include the loss of neurons
and an excessive reduction in synaptic contacts.
• As a result, a person has a high risk of undergoing subsequent
episodes of a mood disorder, even without an external stressor.
• Some clinicians believe that life events play the primary or
principal role in depression; others suggest that life events
have only a limited role in the onset and timing of depression.
73
 Etiology cont……..

• Recent stressful events are the most powerful predictors of

the onset of a depressive episode.

• Stressors that the patient experiences as reflecting negatively

on his/her self-esteem are more likely to produce depression.

• What may seem to be a relatively mild stressor to outsiders

may be devastating to the patient because of particular
idiosyncratic meanings attached to the event.
74
 Etiology cont……..

• The most compelling data indicate that the life event most often
associated with development of depression is losing a parent before
age 11 years.

• The environmental stressor most often associated with the onset of an

episode of depression is the loss of a spouse.

• Another risk factor is unemployment; persons out of work are three

times more likely to report symptoms of an episode of major
depression than those who are employed.
• Guilt may also play a role. 75
 Etiology cont……..

Personality Factors.
• All humans, of whatever personality pattern, can and do become

depressed under appropriate circumstances.

• OCD, histrionic, and borderline—may be at greater risk for
depression than persons with antisocial or paranoid personality
disorder
• Patients with dysthymic disorder & cyclothymic disorder are at risk
of later developing MDD or bipolar I disorder.

76
 Etiology cont……..

Psychodynamic theories of Depression

• Defined by Sigmund Freud and expanded by Karl

Abraham is known as the classic view of depression.

• That theory involves four key points:

– Disturbances in the infant–mother relationship during
the oral phase (the first 10 to 18 months of life)
predispose to subsequent vulnerability to depression;
– Depression can be linked to real or imagined object loss
77
 Etiology cont……..

– Introjection of the departed objects is a defense

mechanism invoked to deal with the distress connected

with the object’s loss; and

– Because the lost object is regarded with a mixture of love

and hate, feelings of anger are directed inward at the self.

78
 Etiology cont……..

Cognitive Theory

• Depression results from specific cognitive distortions

present in persons susceptible to depression.

• These distortions, referred to as depressogenic schemata,

are cognitive templates that perceive both internal and

external data in ways that are altered by early experiences.

79
 Etiology cont……..

• Aaron Beck postulated a cognitive triad of depression

– Views about the self—a negative self precept

– About the environment—a tendency to experience the

world as hostile and demanding

– About the future—the expectation of suffering and failure.

• Therapy consists of modifying these distortions.

80
81
 Etiology cont……..

Learned Helplessness theory

• Connects depressive phenomena to the experience of
uncontrollable events.
• The shocked dogs learned that outcomes were independent
of responses, so they had both
– Cognitive motivational deficit ↔ they would not attempt to
escape the shock
– Emotional deficit ↔indicating decreased reactivity to the shock

82
Hopelessness theory

83
 Etiology cont……..
Evolutionary Theory
• depression is an adaptive response to perceived threats in the
environment, and the tendency for depressed persons to withdraw
from the environment in the face of possible threats could be
protective.
• The depressive response in which one decreases

activity, withdraws from social situations, and approaches novel

situation with a negative bias (“that person will think I am a loser”)
could be interpreted as adaptive ways to reduce risk and avoid further
social failures.
84
DIAGNOSIS

• Depressive disorders can take many forms, depending

on their severity and chronicity.

• The disorder that we most associate with “classic”

depression is major depressive disorder.

• It is essential to understand the different varieties of

depressive disorders
 Classification
Depressive disorder include
1 Major depressive disorder (including major depressive
episode)
2 Persistent depressive disorder (dysthymia)
3 Disruptive mood dysregulation disorder
4 Premenstrual dysphoric disorder
5 Substance/medication-induced depressive disorder

6 Depressive disorder due to another medical condition

7 Other specified depressive disorder
8 Unspecified depressive disorder 86
DSM-5 Diagnostic Criteria for Major
Depressive Disorder
Major Depressive Disorder
Duration 2 wk
Symptoms
• Dysphoria or feeling depressed
• Anhedonia
• ↑ or ↓ weight or appetite
• ↑ or ↓ sleep
• ↑ or ↓ activity
• ↓ energy
• Depressing thoughts: worthlessness, guilt
• ↓ concentration
• Suicidal ideation/plan
• Required number of symptoms 5 (1 has to be one of the
first two listed)

• Psychosocial consequences of symptoms Distress or

impaired functioning (social, occupational, or other
significant areas)

• Exclusions (Not better explained by):Medical

illness ,Substance or Other psychiatric disorder like
History of mania orhypomania
 Specifiers Describing Current or Most Recent
Episodes.
These descriptors help characterize the most recent major
depressive episode; all but the first two can also apply to a manic
episode.

• With atypical features. These depressed patients eat a lot and

gain weight, sleep excessively, and have a feeling of being
sluggish or paralyzed. They are often excessively sensitive to
rejection.
• With melancholic features.
This term applies to major depressive episodes characterized by
some of the “classic” symptoms of severe depression.
These patients
• awaken early, feeling worse than they do later in the day.
• They lose appetite and weight,
• feel guilty
• are either slowed down or agitated
• and do not feel better when something happens that they
would normally like
• With anxious distress. A patient has symptoms
of anxiety, tension, restlessness, worry, or fear
that accompanies a mood episode.

• With catatonic features. There are features of

either motor hyperactivity or inactivity.
Catatonic features can apply to major
depressive episodes and to manic episodes
• With mixed features. Manic, hypomanic, and major
depressive episodes may have mixtures of manic and
depressive symptoms.
• With peripartum onset. A manic, hypomanic, or
major depressive episode (or a brief psychotic
disorder) can occur in a woman during pregnancy or
within a month of having a baby
• With psychotic features. Manic and major
depressive episodes can be accompanied by
delusions, which can be mood-congruent or -
incongruent
Specifiers Describing Course of Recurring Episodes

These specifiers describe the overall course of a mood

disorder, not just the form of an individual episode.

• With rapid cycling. Within 1 year, the patient has had at

least four episodes (in any combination) fulfilling criteria
for major depressive, manic, or hypomanic episodes.

• With seasonal pattern. These patients regularly become

ill at a certain time of the year, such as fall or winter
 Specifiers for Depressive Disorders cont….

• Specify current severity:

• Severity is based on the number of criterion symptoms, the

severity of those symptoms, and the degree of functional disability.

• Mild: Few, if any, symptoms in excess of those required to make

the diagnosis are present, the intensity of the symptoms is

distressing but manageable, and the symptoms result in minor

impairment in social or occupational functioning.

94
 Specifiers for Depressive Disorders cont….

• Moderate: The number of symptoms, intensity of symptoms, and/or

functional impairment are between those specified for “mild” and

“severe.”

• Severe: The number of symptoms is substantially in excess of that

required to make the diagnosis, the intensity of the symptoms is

seriously distressing and unmanageable, and the symptoms

markedly interfere with social and occupational functioning.

95
Dysthymic Disorder
• Dysthymic disorder (also called dysthymia) is
the presence of depressive symptoms that are
less severe than those of major depressive
disorder.

• Although less severe than a major depressive

disorder, it is often more chronic
• dysthymia also known as persistent depressive
disorder,
• is the presence of a depressed mood that lasts
most of the day and is present almost
continuously.
• There are associated feelings of inadequacy,
guilt, irritability, and anger; withdrawal from
society; loss of interest; and inactivity and lack
of productivity.
DSM-5 Diagnostic Criteria for Persistent Depressive
Disorder

Duration 2+ yr (1+ yr for children) ≤2-mo symptom free during

illness
Symptoms Depressed mood most of the time
• ↓ appetite
• ↓ or ↑ sleep
• ↓ energy
• ↓ self-esteem
• ↓ concentration/decision making ability
• Hopelessness
Required number of symptoms First symptom and 2+ of rest
Psychosocial consequences of symptoms Distress and
functional impairment.
Minor Depressive Disorder
• episodes of depressive symptoms that are less severe
than those seen in major depressive disorder.
• The difference between dysthymia and minor
depressive disorder is primarily the episodic nature of
the symptoms in the latter.
• Between episodes, patients with minor depressive
disorder have a euthymic mood, but patients with
dysthymia have virtually no euthymic periods.
Recurrent brief depressive disorder
• Characterized by brief periods less than 2 weeks
(typically 2–3 days with complete recovery)

• not having occurred only in relation to menstrual

cycle during which depressive episodes are
present.
• Patients meet the diagnostic criteria for MDD if
their episodes lasted longer.
100
Double Depression.

• 40 percent of patients with major depressive disorder also meet the

criteria for dysthymia, a combination often referred to as double

depression.

• Have a poorer prognosis than patients with only major depressive

disorder

• The treatment of patients with double depression should be directed

toward both disorders 101

 Disruptive mood dysregulation disorder
• A child’s mood is persistently negative between frequent, severe
explosions of temper
• chronic, severe persistent irritabilty. With two prominent clinical
manifestations,
first - frequent temper outbursts typically occur in response to
frustration and can be verbal or behavioral (in the form of aggression
against property, self, or others). occur frequently ; on average, three
or more times per week; over at least 1 year in at least two settings
such as in the home and at school, and they must be developmentally
inappropriate . 102
 Disruptive mood dysregulation disorder

• The second- severe irritability consists of chronic, persistently

irritable or angry mood that is present between the severe temper
outbursts. Which is characteristic of the child, being present
most of the day, nearly every day, and noticeable by others in
the child's environment
• Must be before age 10 years, and the diagnosis should not be
applied to children with a developmental age of less than 6 years
• Diagnosis should be restricted to age groups similar to those in
which validity has been established (7-18 years).
103
 Postpartum blues

• Begins 2-4 day postpartum, peaks within 10 days and subsides

usually within 3 weeks after delivery.
• Transient period of mild depression, mood instability, anxiety,
decreased concentration;
• Usually mild or absent: feelings of inadequacy, anhedonia,

• increases the risk for a postpartum major depressive episode

104
 MAJOR DEPRESSIVE DISORDER WITH PERIPARTUM ONSET (POSTPARTUM
DEPRESSION)

• MDD that occurs during pregnancy or in the 4 wk

following delivery.
• Typically lasts 2-6 month; residual symptoms can last up
to 1 yr .
• Usually associated with mania, but also with MDE.
• Severe symptoms include extreme disinterest in baby,
suicidal and infanticidal ideation
105
 postpartum depression cont……

• The risk of postpartum episodes with psychotic features

is particularly increased for women with ;
1 prior postpartum mood episodes
2 prior history of a depressive or bipolar disorder
(especially bipolar I do)
3 those with a family history of bipolar disorders.

106
 postpartum depression cont……
psychosocial factors: stressful life events,
:unemployment,
:marital conflict,
:lack of social support,
:unwanted pregnancy,
:colicky or sick infant

107
Prognosis
• impact on child development: increased risk
of cognitive delay, insecure attachment,
behavioral disorders .
• Treatment of mother improves outcome for
child at 8 month through increased mother-child
interaction.
 Premenstrual dysphoric disorder

• Higher prevalence of depressive disorders in women due

to premenstrual affective changes
• Prevalence1.8% and 5.8%
• A few days before her menses, a woman experiences
symptoms of depression and anxiety dysphoria, tension,
irritability, hostility, and labile mood accompanied by
behavioral and physical symptoms.

109
 Premenstrual dysphoric disorder

• Women with severe premenstrual complaints appear to have higher

rates of lifetime major mood disorders

• Many individuals, as they approach menopause, report that

symptoms worsen. Symptoms cease after menopause

• Heritability range between 30% and 80%, with the most stable

component of premenstrual symptoms estimated to be about 50%

heritable.
110
 Depressive disorder due to another
medical condition

• A variety of medical and neurological conditions can produce

depressive symptoms; these need not meet criteria for any of the

conditions above .

• Mood disturbance in this case is etiologically related to the

general medical condition through a physiological mechanism

111
112
 Substance/medication- induced depressive
disorder

• Alcohol or other substances (intoxication or withdrawal) can

cause depressive symptoms; these need not meet criteria for
any of the conditions above .
• The depressive symptoms persist beyond the expected length
of physiological effects, intoxication, or withdrawal period.
• Intense depressive symptoms can last for a long period after
the cessation of substance use.
113
114
Other specified, or unspecified, depressive
disorder

• Use one of these categories when a patient has

depressive symptoms that do not meet the criteria

for the depressive diagnoses above or for any

other diagnosis in which depression is a feature

115
Depression in Children and Adolescents

• symptoms of depression in children can present as School

phobia & Excessive clinging to parents .
• Poor academic performance

• Substance abuse
• Antisocial behavior
• Sexual promiscuity

• Truancy

• Running away may be symptoms of depression in

adolescents 116
 Depression in the Elderly

 Affects about 15% of community residents >65 yr old; up to 50%

in nursing homes
 High suicide risk due to social isolation, chronic medical illness,
decreased independence
 Suicide peak: males aged 80-90; females aged 50-65
 Be correlated with low socioeconomic status, the loss of a spouse,
a concurrent physical illness, and social isolation

117
 Good prognostic factor for MDD

• Mild episodes
• The absence of psychotic symptoms
• Short hospital stay and no more than one previous
hospitalization for major depressive disorder
• Solid friendships during adolescence,
• Stable family functioning, and generally sound social
functioning for the 5 years preceding the illness
• Absence of a comorbid psychiatric disorder and of a
personality disorder
• An advanced age of onset
 Poor prognostic factor for MDD

• coexisting dysthymic disorder

• abuse of alcohol and other substances
• anxiety disorder symptoms
• history of more than one previous depressive episode.
• Men are more likely than women to experience a
chronically impaired course.
 Suicide and deliberate self harm

• There are about 5000 suicides each year in England

and Wales, of which 400-500 involve overdoses of
antidepressants.
• Deliberate self harm is 20-30 times commoner.
• Not all people who commit suicide have psychiatric
illness, but, among those who do, depression is the
commonest illness and
• 15% of depressed patients eventually kill themselves.
• Assessment of risk is thus important and
guides treatment.
• Many older antidepressants are often fatal in
overdose
• While the newer effective drugs—such as
selective serotonin reuptake inhibitors,
lofepramine, and others—are safer and should
be used with high risk patients.
 Suicide or deliberate self harm
Features to be assessed

• Motive
• Circumstances of attempt
• Psychiatric disorder
• Precipitating and maintaining problems
• Coping skills and support
• Risk
High risk indicators for suicide

• Male
• Age > 40 years
• Family history of suicide
• Unemployed
• Socially isolated
• Suicide note
• Continued desire to die
• Hopelessness, sees no future
• Misuse of drugs or alcohol
• Psychiatric illness (especially depression, but also
• schizophrenia, personality disorder)
1. Kaplan & sadock’s comprehensive textbook of psychiatry 10th
edition
2. kaplan and sadok’s synopsis of psychiatry , 12th edition
3. DSM-5th edition
4. Mario_Maj,_Norman_Sartorius_Depressive_DisordersBook
Thank you