DEPRESSIVE DISORDERS

OUTLINE
• INTRODUCTION
• AETIOLOGY/THEORIES
• EPIDEMIOLOGY
• CLASSIFICATION & PRESENTATION
• MANAGEMENT
• PREVENTION
• COMPLICATIONS
 Introduction
MOOD DISORDERS

ELEVATED MOOD DEPRESSIVE

(Hypo/hyper MOOD BIPOLAR DISORDERS
Mania DISORDERS
 Introduction
• Depressive disorders are part of the “mood disorders” also
called “affective disorders”
• Are pervasive/widespread alterations in emotions
• Are characterized by pathological changes/disturbances in
mood (not thought) with or without associated anxiety or
elation.
• Are very common with a high level of morbidity and mortality
• The mood change is usually accompanied by a change in the
overall level of activity.
• Most of these disorders tend to be recurrent, and the onset of
individual episodes is often related to stressful events or
situations.
 THEORIES
“Monoamine (catecholamine)” theory (1965)
The underlying biological or neuroanatomical basis for depression is a
deficiency of central noradrenergic and/or serotonergic transmission in
the CNS.
Supported by:
1. Pharmacological effect of antidepressants (TCA, MAOI)
2. In the past, medication of hypertension with reserpine induced
depression (Alpha adrenergic blocker)
Contradictions:
1. Several drugs (e.g. cocaine) increase the amount of these neurotransmitters in the
CNS but are unable to treat depression
2. The effect of antidepressants on neurotransmitter levels is relatively quick but
onset of antidepressant action is significantly delayed
 THEORIES
“Receptor theory“ = The problem is in up-regulation of post-
synaptic receptors and alterations in their sensitivity
Supported by:
The antidepressant treatment increases the amount of
monoamines in CNS and thereby gradually normalize the
density/sensitivity of their receptors
The precise pathophysiology of depression remains unsolved
 The 4P/Biopsychosocial factors
4Ps Biological Psychological Social
Predisposing Genetic factors Physical Personality e.g Luck of social
health e.g Chronic avoidant and support
diseases/pain dependent
Sex ( F>M) personalities
Old age
Past history
Precipitating Postpartum period Traumatic events- Social isolation, or
Medication side effects bereavement, past history of child
(Triggers)
Drug abuse stress, poverty, abuse
 The 4P/Biopsychosocial factors
4Ps Biological Psychological Social
Perpetuatin Irregular sleep Unemployment, Social stigma
g patterns homelessness, Social isolation
Poor copying strategies
Drug abuse

Protective Early diagnosis and Positive copying Strong/good social

treatment mechanisms support
Healthy relationships
 EPIDEMIOLOGY
• At a global level, over 300 million people are estimated to suffer
from depression, equivalent to 4.4% of the world’s population
(WHO 2017)
• More common among females (5.1%) than males (3.6%). (WHO
2017)
• Prevalence rates vary by age, peaking in older adulthood (above
7.5% among females aged 55-74 years, and above 5.5% among
males).
• Depression also occurs in children and adolescents below the age
of 15 years, but at a lower level than older age groups
• The prevalence of depression increased by an additional 27.6%
globally during the coronavirus disease 2019 (COVID-19)
pandemic (2020 to 2021)
 EPIDEMIOLOGY
Uganda:
A Prevalence of depression in Uganda: A systematic
review and meta-analysis study by Mark Mohan Kaggwa,
Sarah Maria Najjuka, Felix Bongomin, Mohammed A.
Mamun, Mark D. Griffiths, October 2022 indicated a
pooled prevalence of depression of 30.2%
 EPIDEMIOLOGY
Category Prevalence
Refugees 67.6%
War victims 36.0%
Individuals living with HIV 28.2%
Postpartum or pregnant mothers 26.9%
University students 26.9%
Children and adolescents 23.6%;
Caregivers of patients 18.5%
CLASSIFICATION-DSM-5
 Disruptive Mood Dysregulation Disorder-11

A-Severe recurrent temper outbursts E-Criteria A–D have been present for 12
manifested verbally (e.g., verbal rages) or more months. Throughout that time,
and/or behaviorally (e.g., physical the individual has not had a period
aggression toward people or property) lasting 3 or more consecutive months
that are grossly out of proportion in without all of the symptoms in Criteria
intensity or duration to the situation or A–D.
provocation. F-Criteria A and D are present in at least
B-The temper outbursts are inconsistent two of three settings (i.e., at home, at
with developmental level. school, with peers) and are severe in at
C-The temper outbursts occur, on least one of these.
average, three or more times per week. G-The diagnosis should not be made for
D-The mood between temper outbursts the first time before age 6 years or after
age 18 years.
is persistently irritable or angry most of
the day, nearly every day, and is H- By history or observation, the age at
observable by others (e.g., parents, onset of Criteria A–E is before 10 years.
teachers, peers).
 Disruptive Mood Dysregulation Disorder-11

I-There has never been a distinct period • K-The symptoms are not
lasting more than 1 day during which the attributable to the physiological
full symptom criteria, except duration, effects of a substance or to
for a manic or hypomanic episode have another medical or neurological
been met.
condition.
J-The behaviors do not occur exclusively • Note:
during an episode of major depressive
disorder and are not better explained by
1. DMD is common among children
another mental disorder (e.g., autism 2. Onset must be before age 10
spectrum disorder, posttraumatic stress years, and the diagnosis should
disorder, separation anxiety disorder, NOT be applied to children less
persistent depressive disorder than 6 years.
[dysthymia]).
 Differentials

1. Bipolar disorders.
2. Oppositional defiant disorder.
3. Attention-deficit/hyperactivity
disorder, major depressive
disorder,
4. anxiety disorders,
5. Autism spectrum disorder.
 Major Depressive Disorder-MDD
A-Five (or more) of the following 3-Significant weight loss when not
symptoms have been present during the dieting or weight gain (e.g., a change
same 2-week period and represent a
of more than 5% of body weight in a
change from previous functioning; at
least one of the symptoms is either (1)
month), or decrease or increase in
depressed mood or (2) loss of interest or appetite nearly every day. ( failure to
pleasure. make expected weight gain in
1-Depressed mood most of the day, children)
nearly every day, as indicated by either 4-Insomnia or hypersomnia nearly
subjective report (e.g., feels sad, empty, every day.
hopeless) o observation made by others
(e.g. appears tearful). 5-Psychomotor agitation or
2-Markedly diminished interest or retardation nearly every day
pleasure in all, or almost all, activities (observable by others, not merely
most of the day, nearly every day (as subjective feelings of restlessness or
indicated by either subjective account or being slowed down).
observation).
 Major Depressive Disorder-MDD
6-Fatigue or loss of energy nearly every B-The symptoms cause clinically
day. significant distress or impairment
7-Feelings of worthlessness or excessive in social, occupational, or other
or inappropriate guilt (which may be
important areas of functioning.
delusional) nearly every day (not
merely self-reproach or guilt about C- The episode is not attributable
being sick). to the physiological effects of a
8-Diminished ability to think or substance or to another medical
concentrate, or indecisiveness, nearly condition.
every day (either by subjective account
or as observed by others).
Note: Criteria A–C represent a
9-Recurrent thoughts of death (not just
major depressive episode.
fear of dying), recurrent suicidal
ideation without a specific plan, or a
suicide attempt or a specific plan for
committing suicide.
 Major Depressive Disorder-MDD
D-The occurrence of the major E-There has never been a manic
depressive episode is not episode or a hypomanic
better explained by episode.
schizoaffective disorder, Note: This exclusion does not
schizophrenia, apply if all of the manic-like or
schizophreniform disorder, hypomanic-like episodes are
delusional disorder, or other substance-induced or are
specified and unspecified attributable to the physiological
schizophrenia spectrum and effects of another medical
other psychotic disorders. condition.
 Differentials
1. Manic episodes with 3. Substance/medication-
irritable mood or mixed induced depressive or bipolar
disorder.
episodes.
4. Attention
2. Mood disorder due to
deficit/hyperactivity disorder.
another medical condition.
 Persistent Depressive Disorder (Dysthymia)
A-Depressed mood for most of the day,
for more days than not, as indicated by
C-During the 2-year period
either subjective account or
observation by others, for at least 2 (1 year for children or
years.( In children and adolescents, adolescents) of the
mood can be irritable and duration disturbance, the individual
must be at least 1 year.
has never been without the
B-Presence, while depressed, of two (or
symptoms in Criteria A and
more) of the following:
B for more than 2 months at
-Poor appetite or overeating.
a time..
-Insomnia or hypersomnia.
-Low energy or fatigue.
-Low self-esteem.
-Poor concentration or difficulty making
decisions.
-Feelings of hopelessness.
 Persistent Depressive Disorder (Dysthymia)
D-Criteria for a major depressive G-The symptoms are not
disorder may be continuously attributable to the physiological
present for 2 years. effects of a substance (e.g., a
E-There has never been a manic drug of abuse, a medication) or
episode or a hypomanic episode, another medical condition (e.g.
and criteria have never been met for hypothyroidism).
cyclothymic disorder.
H-The symptoms cause clinically
F-The disturbance is not better significant distress or
explained by a persistent impairment in social,
schizoaffective disorder, occupational, or other
schizophrenia, delusional disorder, important areas of functioning
or other specified or unspecified
schizophrenia spectrum and other
psychotic disorder.
 SPECIFIERS
 With anxious distress  In partial remission
 With mixed features  In full remission
 With melancholic  Early onset: If onset is
features before age 21 years.
 With atypical features  Late onset: If onset is
 With mood-congruent at age 21 years or
psychotic features older.
 With mood-incongruent
psychotic features
 With peripartum onset
 SPECIFIERS
Specify if (for most recent 2 years of With intermittent major
persistent depressive disorder): depressive episodes, without
With pure dysthymic syndrome: Full current episode: Full criteriafor a
criteria for a major depressive episode major depressive episode are not
have not been met in at least the currently met, but there has been
preceding 2 years.
one or more major depressive
With persistent major depressive episodes in at least the preceding 2
episode: Full criteria for a major
yearS
depressive episode have been met
throughout the preceding 2-year period.
With intermittent major depressive
episodes, with current episode: Full
criteria for a major depressive episode are
currently met, but there have been
periods of at least 8 weeks in at least the
preceding 2 years with symptoms below
the threshold for a full major depressive
episode.
 SPECIFIERS
Specify current severity:
Mild
Moderate
Severe
 DIFFERENTIALS
 Major depressive disorder.
 Psychotic disorders.
 Depressive or bipolar and related disorder due to
another medical condition.
 Substance/medication-induced depressive or
bipolar disorder.
 Personality disorders.
 Premenstrual Dysphoric Disorder
A-In the majority of B-One (or more) of the
menstrual cycles, at least following symptoms must be
five symptoms must be present:
present in the final week 1-Marked affective lability (e.g.,
mood swings; feeling suddenly sad
before the onset of menses,
or tearful, or increased sensitivity to
start to improve within a rejection).
few days after the onset of 2-Marked irritability or anger or
menses, and become increased interpersonal conflicts.
minimal or absent in the 3-Marked depressed mood, feelings
of hopelessness, or self-deprecating
week postmenses. thoughts.
4-Marked anxiety, tension, and/or
feelings of being keyed up or on
edge.
 Premenstrual Dysphoric Disorder
C-One (or more) of the 4-Marked change in appetite;
following symptoms must overeating; or specific food
additionally be present, to cravings.
reach a total of five symptoms 5-Hypersomnia or insomnia.
when combined with 6-A sense of being
symptoms from Criterion B overwhelmed or out of
above. control.
1-Decreased interest in usual 7-Physical symptoms such as
activities (e.g., work, school, breast tenderness or swelling,
friends, hobbies). joint or muscle pain, a
2-Subjective difficulty in sensation of “bloating,” or
concentration. weight gain.
3-Lethargy, easy fatigability, or
marked lack of energy.
 Premenstrual Dysphoric Disorder
D-The symptoms are E-The disturbance is not
associated with clinically merely an exacerbation of
significant distress or the symptoms of another
interference with work, disorder, such as major
school, usual social depressive disorder, panic
activities, or relationships disorder, persistent
with others (e.g., depressive disorder
avoidance of social (dysthymia), or a
activities; decreased personality disorder
productivity and efficiency (although it may co-occur
at work, school, or home). with any of these
disorders).
.
 Premenstrual Dysphoric Disorder
F-Criterion A should be confirmed. by prospective daily
ratings during at least two symptomatic cycles.
(Note: The diagnosis may be made provisionally prior to this
confirmation.)
G-The symptoms are not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication,
other treatment) or another medical condition (e.g.,
hyperthyroidism).
 Differentials
 Premenstrual syndrome. .
 Dysmenorrhea.
 Bipolar disorder,
 major depressive disorder,
 persistent depressive disorder(dysthymia).
 Substance/Medication-Induced
Depressive Disorder
A-A prominent and persistent
disturbance in mood that predominates
C-The disturbance is not better
in the clinical picture and is characterized explained by a depressive disorder that is
by depressed mood or markedly not substance/ medication-induced. Such
diminished interest or pleasure in all, or evidence of an independent depressive
almost all, activities. disorder could include the following:
The symptoms preceded the onset of the
B- There is evidence from the history, substance/medication use; the
physical examination, or laboratory symptoms persist for a substantial period
findings of both (1) and (2): of time (e.g., about 1 month) after the
1-The symptoms in Criterion A cessation of acute withdrawal or severe
developed during or soon after intoxication; or there is other evidence
substance intoxication or withdrawal or suggesting the existence of an
after exposure to a medication. independent non-substance/medication-
induced depressive disorder (e.g., a
2-The involved substance/medication is history of recurrent
capable of producing the symptoms in non-substance/medication-related
Criterion A. episodes).
 Substance/Medication-Induced
Depressive Disorder
D-The disturbance does
SPECIFIERS
not occur exclusively With onset during intoxication:
during the course of a If criteria are met for
delirium. intoxication with the substance
E-The disturbance causes and the symptoms develop
during intoxication.
clinically significant
With onset during withdrawal:
distress or impairment in If criteria are met for
social, occupational, or withdrawal from the substance
other important areas of and the symptoms develop
functioning during, or shortly after,
withdrawal.
 Differentials
 Substance intoxication and withdrawal.
 Primary depressive disorder.
 Depressive disorder due to another medical condition.
 Depressive Disorder
Due to Another Medical Condition
A-A prominent and persistent period
of depressed mood or markedly D-The disturbance does not
diminished interest or pleasure in all, occur exclusively during the
or almost all, activities that
predominates in the clinical picture. course of a delirium.
B-There is evidence from the E-The disturbance causes
history, physical examination, or clinically significant distress or
laboratory findings that the impairment in social,
disturbance is the direct
occupational, or other
pathophysiological consequence of
another medical condition. important areas of
functioning.
C- The disturbance is not better
explained by another mental
disorder (e.g., adjustment disorder,
with depressed mood, in which the stressor is a
serious medical condition).
 Specifiers
With depressive features:
Full criteria are not met for a major depressive
episode.
With major depressive–like episode:
Full criteria are met (except Criterion C) for a major
depressive episode.
With mixed features:
Symptoms of mania or hypomania are also present
but do not predominate in the clinical picture.
 Differentials
Depressive disorders not due to
another medical condition.
Medication-induced depressive
disorder.
Adjustment disorders.
 Other Specified Depressive Disorder
This category applies to Recurrent brief depression:
presentations in which Concurrent presence of depressed
symptoms characteristic of a mood and at least four other
symptoms of depression for 2–13
depressive disorder that cause days at least once per month (not
clinically significant distress or associated with the menstrual cycle)
impairment in social, for at least 12 consecutive months in
occupational, or other an individual whose presentation has
important areas of functioning never met criteria for any other
depressive or bipolar disorder and
predominate BUT do NOT does not currently meet active or
meet the FULL CRITERIA for residual criteria for any psychotic
any of the disorders in the disorder.
depressive disorders
diagnostic class.
 Other Specified Depressive Disorder
Short-duration depressive episode (4–13 days):
Depressed affect and at least four of the other eight
symptoms of a major depressive episode associated with
clinically significant distress or impairment that persists for
more than 4 days, but less than 14 days, in an individual
whose presentation has never met criteria for any other
depressive or bipolar disorder, does not currently meet
active or residual criteria for any psychotic disorder, and
does not meet criteria for recurrent brief depression.
 Other Specified Depressive Disorder
Depressive episode with insufficient symptoms:
Depressed affect and at least one of the other eight
symptoms of a major depressive episode associated with
clinically significant distress or impairment that persist for at
least 2 weeks in an individual whose presentation has never
met criteria for any other depressive or bipolar disorder,
does not currently meet active or residual criteria for any
psychotic disorder, and does not meet criteria for mixed
anxiety and depressive disorder symptoms
 GENERAL SPECIFIERS
A-With anxious distress:
Anxious distress is defined as the presence of at least two of
the following symptoms during the majority of days of a
major depressive episode or persistent depressive disorder
(dysthymia):
•Feeling keyed up or tense.
•Feeling unusually restless.
•Difficulty concentrating because of worry.
•Fear that something awful may happen.
• Feeling that the individual might lose control of himself or
herself.
 GENERAL SPECIFIERS
B-Specify current severity:
1.Mild: Two symptoms.
2.Moderate: Three symptoms.
3.Moderate-severe: Four or five symptoms.
4.Severe: Four or five symptoms and with
motor agitation.
 GENERAL SPECIFIERS
With mixed features:
A-At least three of the following manic/hypomanic
symptoms are present nearly everyday during the majority
of days of a major depressive episode:
1.Elevated, expansive mood.
2.Inflated self-esteem or grandiosity.
3. More talkative than usual or pressure to keep talking.
4.Flight of ideas or subjective experience that thoughts are racing.
5.Increase in energy or goal-directed activity (either socially, at work or
school, or sexually
6.Increased or excessive involvement in activities that have a high
potential for painful consequences (e.g., engaging in unrestrained
buying sprees, sexual indiscretions, foolish business investments).
7. Decreased need for sleep (feeling rested despite sleeping less than
usual; to be contrasted with insomnia)
 GENERAL SPECIFIERS
B-Mixed symptoms are observable by others and
represent a change from the person’s usual
behavior.
C-For individuals whose symptoms meet full criteria
for either mania or hypomania, the diagnosis
should be bipolar I or bipolar II disorder.
D-The mixed symptoms are not attributable to the
physiological effects of a substance (e.g., a drug of
abuse, a medication or other treatment).
 GENERAL SPECIFIERS
C-With melancholic features:
A. One of the following is present during the most severe period of the current
episode:
1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even
temporarily, when something good happens).
B-Three (or more) of the following:
•A distinct quality of depressed mood characterized by profound despondency,
despair, and/or moroseness or by so-called empty mood.
•Depression that is regularly worse in the morning.
•Early-morning awakening (i.e., at least 2 hours before usual awakening).
•Marked psychomotor agitation or retardation.
•Significant anorexia or weight loss.
• Excessive or inappropriate guilt.).
 GENERAL SPECIFIERS
With atypical features:
This specifier can be applied when these
features predominate during the majority of
days of the current or most recent major
depressive episode or persistent depressive
disorder.
A-Mood reactivity (i.e., mood brightens in
response to actual or potential positive events).
 GENERAL SPECIFIERS
B-Two (or more) of the following:
1.Significant weight gain or increase in appetite.
2. Hypersomnia.
3.Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
4.A long-standing pattern of interpersonal rejection sensitivity
(not limited to episodes of mood disturbance) that results in
significant social or occupational impairment.
C-Criteria are not met for “with melancholic features” or “with
catatonia” during the same episode.
 GENERAL SPECIFIERS
With psychotic features:
Delusions and/or hallucinations are present.:
With mood-congruent psychotic features:
The content of all delusions and hallucinations is consistent with
the typical depressive themes of personal inadequacy, guilt,
disease, death, nihilism, or deserved punishment.
With mood-incongruent psychotic features:
The content of the delusions or hallucinations does not involve
typical depressive themes of personal inadequacy, guilt,
disease, death, nihilism, or deserved punishment, or the
content is a mixture of mood-incongruent and mood-congruent
themes.
 GENERAL SPECIFIERS
With catatonia:
The catatonia specifier can apply to an episode of depression if catatonic
features are present during most of the episode.
With peripartum onset:
This specifier can be applied to the current or, if full criteria are not
currently met for a major depressive episode, most recent episode of major
depression if onset of mood symptoms occurs during pregnancy or in the 4
weeks following delivery.
 GENERAL SPECIFIERS
With seasonal pattern:
This specifier applies to recurrent major depressive disorder.
1.There has been a regular temporal relationship between the onset of
major depressive episodes in major depressive disorder and a particular time
of the year
2.Full remissions (or a change from major depression to mania or
hypomania) also occur at a characteristic time of the year (e.g., depression
disappears in the spring).
3.In the last 2 years, two major depressive episodes have occurred that
demonstrate the temporal seasonal relationships defined above and no
nonseasonal major depressive episodes have occurred during that same
period.
4. Seasonal major depressive episodes (as described above) substantially
outnumber the non-seasonal major depressive episodes that may have
occurred over the individual’s lifetime.
 MANAGEMENT ( Biopsychosocial approach)
PHARMAC ANTI-DEPRESSANTS:
OTHERAPY Tricyclic antidepressants (TCA)
A. Tertiary Amines: Amitriptyline, Butriptyline, Clomipramine,
Dosulepin, Doxepin, Imipramine, Lofepramine, Trimipramine
B. Secondary Amines: Desipramine, Nortriptyline, Protriptyline
C. Others: Dibenzodiazepine derivitive: Dibenzepin

Monoamine oxidase inhibitors (MAOI)

Irreversible: Isocarboxazid, Iproniazid, Phenelzine and
Tranylcypromine
Reversible: Moclobemide and Clorgyline

Selective Serotonin Re-uptake Inhibitors (SSRI)

Fluoxetine Fluvoxamine Paroxetine Sertraline
Citalopram
 MANAGEMENT ( Biopsychosocial approach)
PHARMACOTHERAPY Serotonin-2 Antagonists/Reuptake
Inhibitors (SARI)
Serotonin and Noradrenaline Reuptake
Antidepressants takes a Inhibitors (SNRI)
minimum of 6 months to Noradrenaline and Dopamine Reuptake
take effect Inhibitors (NDRI)
Noradrenaline Reuptake Inhibitors (NaRI)
Noradrenergic/Specific Serotonergic
Antidepressants
(NaSSA)
 MANAGEMENT ( Biopsychosocial approach)
• Cognitive therapy: It aims at correcting the
depressive negative cognitions like hopelessness,
worthlessness, helplessness and pessimistic
ideas and replacing them with new cognitive and
behavioral responses.
• Supportive psychotherapy: Various techniques
are employed to support the patient. They are
reassurance, ventilation, occupational therapy,
relaxation and other activity therapies.
• Group therapy: useful for mild cases of
depression.
• Family therapy: used to decrease intra-familial
and interpersonal difficulties and to reduce or
modify stressors, Electroconvulsive therapy (ECT)
• Behaviour therapy: social skills training, problem
solving techniques, assertiveness training, self-
control therapy, activity scheduling and decision
making techniques.
 COMPLICATIONS
• Excess weight or obesity, which can lead to heart disease and
diabetes
• Alcohol or drug misuse
• Anxiety, panic disorder or social phobia
• Family conflicts (Domestic violence etc)
• Relationship difficulties,
• Reduced productivity
• Social isolation
• Suicidal feelings, suicide attempts or suicide
• Homicide
• Self-mutilation, such as cutting
 PREVENTION
1. Embrace positive coping mechanisms to stressors
2. Awareness creation about depressive disorders
3. Avoid use of illicit drugs that can induce depression
4. Health lifestyle ( good nutrition/diet, regular exercises,
adequate sleep, etc)
5. Early recognition/detection and management
6. Seek professional help/advise
7. Have regular mental state assessments/check ups