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DEPRESSIVE

DISORDERS
Ponciano Z. Jerez Jr., MD, FPPA(Life)

SAD
vs
DEPRESSED

Depression:
Common Symptoms
MOOD
Prolonged
unhappiness
Loss of interest or
pleasure
Hopeless
Helpless

PSYCHOLOGICAL

PHYSICAL

Guilt / Negative
attitude to self
Unable to think
clearly / quickly
Poor concentration
/ memory
Thoughts of death
or suicide

Agitation or
slowing down
Tiredness / Lack of
energy
Sleep problems
Weight loss /
increase
Disturbed appetite

FACTS ABOUT DEPRESSION


Lifetime prevalence rate of 10 - 25% for females and 5
- 12% for males
Hormonal, differing psychosocial stressor and
learned helplessness
Learned helplessness
Differing psychosicial stressors

Highest rates between 25 - 44 years old


Increasing in people less than 20 years old

Genetic Factors
10 25% risk for a child if one parent has mood
disorder
1.5 - 3x greater risk in patients with a (+) family
history.
Herditability is about 40-50% specially in severe
depression
Monozygotic or identical twins double risk vs
dizygotic or fraternal twin studies

Psychosocial Factors such as Life events and Environmental Stress

Losing a parent before the age of 11


Loss of spouse
Unemployment
Recent life events are the most powerful
predictors of the onset of a depressive episode

Diathesis model
Individual vulnerability

Cognitive theory (triad of depression)


1. view about self (negative self-percept)
2. about the environment (hostile
demanding world)
3. about the future (suffering and failure)

and

Biologic factors
Probable cause: depletion of serotonin and
noradrenaline at the synapses
In relation to genetics, one gene isolated 5HTT
which helps regulate neurotransmitter Serotonin

Biochemical Basis of Depression


The Amine Hypothesis:
Depression arises as a consequence of a
disturbance of one or more of the biogenic
amine neurotransmitters in the brain. This forms
the basis of the monoamine hypothesis of
depression, which suggests that a relative deficit
in NA, 5HT and DA is responsible for the
symptoms of depression.

Biochemical Basis of Depression

The amine hypothesis postulates that the


changes in mood (possibly linked to a deficit
in 5-HT), deficit in drive and motivation
(possibly linked to DA and NE) are the results
of hypoactivity of these neurotransmitters.

The Amine Hypothesis


Antidepressants act on various biochemical
processes in the brain by which the amine
neurotransmitters prolong their physiologic
actions and thereby attenuate the main
symptoms of depression.

Neurotransmitters and Clinical


Symptoms
NORADRENALIN

SEROTONIN

ANXIETY

APATHY
LACK OF
INTEREST

MOOD
THOUGHTS

LACK OF
ENERGY

TENSE
IRRITABLE

APPETITE
SEX

LACK OF
PLEASURE

DOPAMINE

The Role of Noradrenalin


There is accumulating evidence that the NA system
modulates drive and motivation, aside from
learning and memory

Noradrenergic
Pathways

The Role of Serotonin


The serotonergic system modulates impulsiveness
and mood.

Serotonergic Pathways

Dopaminergic Pathways

Depressive Disorders
Major Depressive Disorder
Disruptive Mood Dysregulation Disorder
Dysthymic Mood Disorder
Premenstrual Dysphoric Disorder
Substance/Medication-Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition

Major Depressive
Disorder

Major Depressive Disorder


Criterion symptom must be present nearly
everyday

Insomnia

and

fatigue- usual
complaint

presenting

Depression in Primary Care Setting


9% of patients in primary care settings

30% of acutely hospitalized adults


40% of older patients in long-term care
80% of severely depressed patients think of suicide

19

Neurotransmitters and Clinical


Symptoms
NORADRENALIN

SEROTONIN

ANXIETY

APATHY
LACK OF
INTEREST

MOOD
THOUGHTS

LACK OF
ENERGY

TENSE
IRRITABLE

APPETITE
SEX

LACK OF
PLEASURE

DOPAMINE

Major Depressive Disorder:

DSM Criteria
A.

5 or more of the following symptom


2-week period either depressed mood or loss of interest

1.
2.
3.
4.
5.
6.
7.
8.
9.

Sad, depressed mood, most of the day, nearly every day for
two weeks
Loss of interest and pleasure in usual activities
Difficulties sleeping
Shift in activity level
Changes in appetite and weight loss/gain
Loss of energy, fatigue
Negative self-concept, self-blame, guilt, worthlessness
Difficulty concentrating
Recurrent thoughts of death or suicide

B. Symptom cause significant distress or impairment


in social and occupational or other areas of
functioning
C. Not due to substance abuse or any medical
condition
D. Occurrence of major depressive episode is
not due to other psychotic disorder
E. No hypomanic or manic episode

Associated features
Tearfulness
Irritability
Brooding
Obsessive rumination
Anxiety
Phobias
Separation anxiety(children)

Prevalence
(Major Depressive disorder)

18-29 years old > 60 years old


Female > male

Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder


Chronic, severe persistent irritability

Disruptive Mood Dysregulation Disorder


A. Severe recurrent temper outbursts manifested
behaviorally that are grossly out of proportion in
intensity or duration to the situation
B. Temper outburst inconsistent with
developmental level
C. Temper outbursts occur 3x or more per week

Disruptive Mood Dysregulation Disorder


D. Mood between temper outbursts, persistently angry
or irritable most of the day and observable by other

E. Criteria A-D present for 12 or more months

Prevalence
(Disruptive Mood Dysregulation Disorder)

Male > Female

Dysthymic Disorder

Dysthymic Disorder
presence of depressed/irritable mood that has
persisted at least 2 years (adults) 1 year (children)

The main feature


anhedonia
the inability to experience pleasure, social
withdrawal, low self-esteem

Dysthymic mood disorder

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)

Premenstrual
Dysphoric Disorder

Premenstrual
Dysphoric Disorder
Essential

expression of mood la bility


Irritability
dysphoria,
anxiety

symptoms that occur repeatedly during the pre menstrual phase

Premenstrual Dysphoric Disorder

A. In the majority of menstrual cycles, at least 5


symptoms must be present in the final week
before the onset of menses, start to improve
within a few days after the onset of menses, and
become minimal or absent in the week
postmenses

B. 1 or more of the

following symptoms must be

present:
Marked affective lability
Marked irritability or anger or increased
interpersonal conflicts
Marked depressed mood, feelings of
hopelessness
Marked anxiety, tension, and/or feelings of being
keyed up or on edge

C. One (or more) of the following symptoms


must additionally be present, to reach a total
of 5 symptoms when combined with
symptoms from Criterion B above.
1.
2.
3.
4.
5.
6.
7.

Decreased interest in usual activities


Subjective difficulty in concentration
Lethargy, easy fatigability, or marked lack of energy
Marked changes in appetite; overeating;
Hypersomnia or insomnia
Sense of being overwhelmed or out of control
Physical symptoms such as breast tenderness or swelling, joint or muscle
pain, a sensation of bloating or weight gain

D. The symptoms are associated with clinically


significant distress or interference with work, school,
usual social activities, or relationships with others
E. The disturbance is not merely an exacerbation of
the symptoms of another disorder, such as major
depressive disorder, panic disorder, persistent
depressive disorder (dysthymia), or a personality
disorder (although it may co-occur with any of these
disorders).

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 or another
medical condition

Associated Features Supporting Diagnosis

Delusions and hallucinations late luteal phase of the


menstrual cycle
premenstrual phase risk period for suicide

Risk and Prognostic Factors


Women who use oral contraceptives fewer
premenstrual complaints than do women who do not
use oral contraceptives

Functional Consequences of Premenstrual


Dysphoric Disorder
marked impairment in the ability to function socially
or occupationally in the week prior to menses

Substance/Medication-Induced
Depressive Disorder

Substance/Medication-Induced Depressive
Disorder
A.

A prominent disturbance in characterized by


depressed mood or markedly diminished interest
or pleasure in all, or almost all, activities

Substance/Medication-Induced Depressive
Disorder
B.

Theres evidence:
The symptoms in Criterion A developed during or
soon after substance intoxication or withdrawal or
after exposure to a medication
The involved substance/medication is capable of
producing the symptoms in Criterion A.

Substance/Medication-Induced Depressive
Disorder
C.
The disturbance is not better explained by a
depressive disorder that is not substance /
medication-induced.

Substance/Medication-Induced Depressive
Disorder
D.
symptoms preceded the onset of the
substance/medication use
symptoms persist for a substantial period of time
(e.g., about 1 month) after cessation of acute
withdrawal or severe intoxication

Substance/Medication-Induced Depressive
Disorder

E.
The disturbance does not occur exclusively
during the course of a delirium
The disturbance causes clinically significant
distress
or
impairment
in
social,
occupational, or other important areas of
functioning

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 diminished interest or pleasure
in all, or almost all, activities that predominates in
the clinical picture

Depressive Disorder Due to Another


Medical Condition
B.
There is evidence from the history, physical
examination, or laboratory findings that the
disturbance is the direct pathophysiological
consequence of another medical condition.

Depressive Disorder Due to Another


Medical Condition
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).

Depressive Disorder Due to Another


Medical Condition
D.
The disturbance does not occur exclusively during
the course of a delirium
E.
The disturbance causes clinically significant distress
or impairment in social, occupational, or other
important areas of functioning

Major Classes of Anti-Depressant Drugs


Monoamine oxidase inhibitors:
First effective antidepressants to be used clinically but are
now used infrequently

Tricyclic Antidepressants:
General uptake inhibitors of biogenic amines that inhibit the
uptake of both 5-HT and NA, and are probably the most
effective drugs for patients who are severely depressed

Selective Serotonin Reuptake Inhibitors


The most commonly used anti-depressants that inhibit the
reuptake of serotonin

Seven Different Types of


Anti-depressants (Stephen Stahl)
Tricyclic
antidepressants
Monoamine oxidase
inhibitors
Selective serotonin
reuptake inhibitors
Serotoninnorepinephrine
reuptake inhibitors

Serotonin-2
antogonism/reuptake
inhibitors
2 antagonism +
serotonin reuptake
inhibition
Selective
norepinephrine and
dopamine reuptake
inhibitors

Summary
Many of the side effects of antidepressants are
attributable to the action of the drug on receptors
that are associated with their antidepressant
actions (such as the adrenoreceptors, muscarinic
receptor and histaminic receptors).
Some side effects are an inevitable consequence of
activation of the serotonergic system and include
the neurological, sexual, and GI side effects. Such
effects occur with the SSRIs, SNRIs and MAOIs.
Dietary interactions are largely confined to the
non-selective MAOIs.

Mood has to be controlled.


Otherwise, its your master.

Thank you!