Depressive Disorders PDF

DEPRESSIVE DISORDERS Dr. Reem Hashem Prof. of Psychiatry Ain Shams University MD, MRCpych  Definition of Depressive Disorders Most people feel sad or irritable from time to time. They may say they're in a bad mood. A mood disorder is different. For nearly 2500 years mood diso...

DEPRESSIVE DISORDERS Dr. Reem Hashem Prof. of Psychiatry Ain Shams University MD, MRCpych  Definition of Depressive Disorders Most people feel sad or irritable from time to time. They may say they're in a bad mood. A mood disorder is different. For nearly 2500 years mood disorders have been described as the most common diseases of mankind. Hippocrates (460–357 BC) described melancholia ("black bile"). The World Health Organization has ranked depression fourth in a list of the most urgent health problems worldwide. Depressive Disorders Etiology: Psycho-socio-biological Model: Over the years there has been a growing body of evidence to suggest that mood disorders result from a complex interplay between biologic processes and environmental factors suggestive of a multifactorial etiology. Psycho-socio-biological Model: 1. Biological 2. Psycho-Social Neurochemical Loss of self- factors esteem Loss of loved Genetic object Neuroendocrine Cognitive regulation theory Learned helplessness  Etiology: 1. Biological Causal Factors a. Genetic Influences b. Neurochemical Factors Family studies have shown that the prevalence of monoamine theory of depression— that mood disorders is approximately two to three times depression was at least sometimes due to an higher among blood relatives of persons with absolute or relative depletion of serotonin , clinically diagnosed unipolar depression than it is in norepinephrine and dopamine at important the population at large. receptor sites in the brain. A specific gene that might be implicated is the serotonin-transporter gene—a gene involved in the transmission and reuptake of serotonin, one of the key neurotransmitters involved in depression.  c. Abnormalities of Hormonal Regulatory and Immune Systems The hypothalamicpituitary- adrenal (HPA) axis, The human stress response is associated with elevated activity of the HPA axis. Blood plasma levels of cortisol are known to be elevated in some 20 to 40 % of outpatients with depression and in about 60 to 80 % of hospitalized patients with severe depression (Thase et al., 2002). Sustained elevations in cortisol can result from increased CRH activation (for example, during sustained stress or threat), increased secretion of ACTH, or the failure of feedback mechanisms. Patients having depression with elevated cortisol also tend to show memory impairments and problems with abstract thinking and complex problem solving (Belanoff et al., 2001) as the prolonged elevations in cortisol, result in cell death in the hippocampus.  2. Psycho-Social: The effects of some psychological factors such as stressful life events are mediated by a cascade of underlying biological changes that they initiate. One way in which stressors may act is through their effects on biochemical and hormonal balances and on biological rhythms (Hammen, 2005; Monroe, 2008). Severely stressful episodic life events play a causal role (most often within a month after the event) in about 20 to 50 % of cases. This relationship between severely stressful life events and depression is much stronger in people who are having their first onset than in those undergoing recurrent episodes. Indeed, Monroe and Harkness (2005) estimated that about 70 % of people with a first onset of depression have had a recent major stressful life event, whereas only about 40 % of people with a recurrent episode have had a recent major life event. Loss of self-esteem: Thinking that one is helpless, unworthy, or useless Loss of loved object: As loss of parent prior to 11 years  Beck’s Cognitive theory: Beck hypothesized that the cognitive symptoms of depression often precede and cause the affective or mood symptoms rather than vice versa. For example, if you think that you are a failure or that you are ugly, it would not be surprising for those thoughts to lead to a depressed mood. Beck calls the negative cognitive triad.  Learned helplessness: Martin Seligman (1974, 1975) first proposed that the laboratory phenomenon known as learned helplessness might provide a useful animal model of depression. In the late 1960s, Seligman and his colleagues noted that laboratory dogs who were first exposed to uncontrollable shocks later acted in a passive and helpless manner when they were in a situation where they could control the shocks. In contrast, animals first exposed to equal amounts of controllable shocks had no trouble learning to control the shocks. It states that when animals or humans find that they have no control over aversive events (such as shock), they may learn that they are helpless, which makes them unmotivated to try to respond in the future. Instead they exhibit passivity and even depressive symptoms.  Epidemiology: 1. Risk and prevalence The lifetime prevalence of developing major depressive disorder is about 17% overall; the prevalence in women is roughly twice the prevalence in men. The risk is similar in different countries and across races. The rate of completed suicide is 10% to 15%. Life time prevalence for dysthymic disorder was 5%. 2. Age of onset. The age of onset can range from childhood to old age; the mean age of onset is about 40 years old. 3. Recurrence Approximately 50% after one episode, 70% after 2 episodes.  Clinical picture: I. Psychological symptoms 1. Depressed mood and sadness (sometimes there is diurnal variation, which means that the symptoms are more severe in the morning). 2. Loss of interest and lack of enjoyment 3. Sense of emptiness, helplessness, hopelessness, worthlessness, pessimism, death wishes, suicidal thoughts, loss of self-esteem, self -blame and guilt. 4. Psychotic symptoms may be found in severe cases as: Delusions: of guilt, nihilism, poverty, hypochondriasis, Hallucinations: auditory, visual etc. (All delusions or hallucination are mood congruent)  II. Physiological symptoms: Diminished appetite, fatigue and loss of energy. Loss of libido. Sleep disturbances: such as insomnia, early morning awakening and interrupted sleep. Pains may be in form of (headache, back pain or any kind of pain). Loss of appetite, loss of weight. (Sometimes-atypical symptoms occur e.g. (increased appetite, hypersomnia). Sometimes disturbed sleep and appetite called vegetative symptoms III. Other symptoms include: 1. Behavioral symptoms Negligence of self-care. Social withdrawal suicidal attempts 2. Motor, cognitive symptoms Difficulty in attention and concentration. Bradyphrenia (Slow thinking), Psychomotor retardation or agitation. 3. Impaired social and occupational functioning  criteria for Major Depressive Disorder DSM5 A. Five (or more) of the following symptoms have been present during the same 2-week B. The symptoms cause clinically period and represent a change from previous significant distress or impairment in functioning; at least one of the symptoms is social, occupational, or other important either (1) depressed mood or (2) loss of interest areas of functioning. or pleasure. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective C. The episode is not attributable to the report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., physiological effects of a substance or appears tearful). (Note: In children and adolescents, can be irritable mood.) another medical condition. 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). D. The occurrence of the major depressive 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than episode is not better explained by 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) schizoaffective disorder, schizophrenia, 4. Insomnia or hypersomnia nearly every day. schizophreniform disorder, delusional disorder, or other specified and unspecified 5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down). schizophrenia spectrum and other psychotic 6. Fatigue or loss of energy nearly every day. disorders. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be E. There has never been a manic episode or delusional) nearly every day (not merely self-reproach or guilt about being sick). a hypomanic episode. 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.  Other forms of depression: Dysthymia: Chronic sub-threshold depression these symptoms remain for at least 2 years. Patients present with a depressed mood for most of the day (at least 2 years in duration for adults and 1 year for children and adolescents) that has not been severe enough to meet the criteria for MDE. Instead of the five symptoms required of MDE, patients must have two of the following: increase or decrease in appetite or sleep, low energy, low self- esteem, poor concentration or decision-making ability, and hopelessness. Comorbid depression with dythymia called double depression.  Other forms of depression: Bereavement and Greif Adjustment Disorder with depressed mood: Mild to moderate symptoms of depression occurred and disappeared within 6 months of significant stressor Depression 2ry to medical illness: depressive symptoms occurred secondary to (temporal relation) some medical condition as DM, MI, CVS Drug Induced depression: some drugs as may causes depression as Steroids, Contraceptive pills, some antihypertensive, Substance abuse Psychotic depression: with delusion or hallucination Depression with somatic syndrome: diurnal variation of symptoms, early morning awakening, retardation or agitation, weight loss and loss of libido  Management of depression: Investigations: Depression is a clinical diagnosis investigations only for exclusion of general medical condition in some cases Assessment of severity via (Hamilton or Beck depression scale) Routine investigation prior to treatment according to side effect profile of treatment. Treatment plan: Management starts with risk assessment, in terms of self-neglect and suicide. Short term management: A. Hospitalization B. ECT C. Pharmacotherapy D. Psychotherapy  Management of depression: Hospitalization if: Suicidal risk, refusal of food or medication. Severe agitation or retardation, psychotic symptoms, severe depression.  Pharmaco-Therapy Tricyclic Antidepressants (TCAs) e.g. Imipramine (Tofranil), Amitriptyline (Tryptizole) Dose: 75 – 150 mg/day). They have unpleasant side effects for some people (dry mouth, constipation, sexual dysfunction, and weight gain may occur). They are not the first line of drugs due to their side anticholinergic and cardiac toxicity side effects. Selective Serotonin Reuptake Inhibitors (SSRIs) e.g. Fluoxetine (20 mg), Fluvoxamine (100-300 mg), Sertraline (50-200 mg) & Citalopram (20-60 mg), Paroxetine (20-60mg). The SSRIs tend to have many fewer side effects and are better tolerated by patients, as well as being less toxic in large doses. The primary negative side effects of the SSRIs are problems with orgasm and lowered interest in sexual activity, although insomnia, increased physical agitation, and gastrointestinal distress also occur in some patients  Pharmaco-Therapy Selective Serotonin Norepinephrine Inhibitors (SNRIs) e.g. Venlafaxine (Efexor) 75mg-150mg. Antipsychotic drugs in case of severe depression or psychotic features as quitapine (qutiapex) 200-600mg daily. C. Electro-convulsive therapy (ECT)  Electro-Convulsive Therapy Severe cases, psychotic symptoms. Refractory to drug treatment, suicidal symptoms. Severe agitation or retardation. 6-12 Sessions  Psychosocial therapy: Family therapy and education for the Patient Cognitive therapy, to eliminate negative thoughts. Supportive psychotherapy. marital therapy. Cognitive behavioral therapy  Phases of treatment Acute phase: 4- 6 weeks Continuation phase: 6-8 months Prophylaxis: Long-term treatment to prevent recurrence. Explain to the patient and relatives that: Expected side effects of drugs, Improvement will build up over two or three weeks. ECT is very safe and is reserved for severe cases and suicidal patients.  Prognosis: About 70% with moderate to severe illness respond to treatment within 6 weeks. Depression is a recurrent disorder in about 50% of cases.  Important information to patients and family Depression is a common illness; it is not weakness or laziness. Although depression is a serious illness with fatal complication it has effective treatment. Guidelines for duration of treatment, doses and follow up should be maintained according to clinician instructions.