Adherence to long-term therapy for chronic illnesses in developed

countries averages 50%. In developing countries, the rates are even

lower.

Noncommunicable diseases (cancer, hypertension, diabetes,etc)

Mental disorders, human immunodeficiency virus/acquired

immunodeficiency syndrome and tuberculosis, together

represented 54% of the burden of all diseases worldwide in 2001

and will exceed 65% worldwide in 2020.

La Depressione : definizioneLa Depressione : definizione

La depressione come fenomeno appare di non facile definizione, in quanto legata indissolubilmente al concetto di umore.

L’umore è una dimensione complessa della vita psichica dell’uomo, nellaquale confluiscono aspetti emozionali, affettivo/sentimentali, cognitivi,

temporali, motivazionali e motori che, se così si può dire, “colora di sé” tutta la vita dell’individuo, costituendo una sorta di griglia percettiva ed

elaborativa con cui si dà significato alla realtà. (Vella, Siracusano1994)

La Depressione : definizioneLa Depressione : definizione

Esiste una linea di continuità che collega la depressione sia alla tristezza, tristezza, esperienza comune e fisiologica,

sia al dolore,dolore, che rappresenta a sua volta uno dei nulei centrali della depressione.

La qualità che fa traghettare dolore e tristezza nella depressione può essere riconosciuta nella loro pervasività,pervasività, nell’interessare psiche e somanell’interessare psiche e soma allo stesso modo, nella loro fissitàfissità, nel non essere più modificabilinon essere più modificabili dalledalle

situazioni esterne,situazioni esterne, tristi o liete, nell’intensità del dolore,nell’intensità del dolore, che tende a congelare vissuti psichici e somatici in un unico blocco

privo di spintaprivo di spinta evolutiva.evolutiva.

Depressione e suicidioDepressione e suicidio

10-15% dei pazienti depressi si suicida

I due terzi tra i pazienti depressi hanno idee suicide

I pazienti depressi con aspetti psicotici considerano talvolta l’uccisione di persone coinvolte nei loro sistemi deliranti

Population projection of US adults with lifetime experience of depressive disorder by age and sex from year 2005 to 2050 (I).

In year 2006 the (weighted) prevalence of lifetime experience of

depressive disorder was 15.7% among 188,292 respondents aged 18

years or older.

Female prevalence was 20.6%, which was about twice as high

as the prevalence among males (11%).

Heo M,, Murphy CF ET AL.Int J Geriatr Psychiatry. 2008 May 23. [Epub ahead of print]

Population projection of US adults with lifetime experience of depressive disorder by

age and sex from year 2005 to 2050 (II).

From year 2005-2050, the total number of US adults with

depressive disorder will increase from 33.9 million to 45.8 million,

a 35% increase.

The increase is projected to be greater in the elderly population

aged >/= 65 years (3.8-8.2, a 117% increase???) than in the young

population aged < 65 years (30.1-37.7, a 25% increase).

Heo M,, Murphy CF ET AL.Int J Geriatr Psychiatry. 2008 May 23. [Epub ahead of print]

Depressione e suicidioDepressione e suicidio

10-15% dei pazienti depressi si suicida

I due terzi tra i pazienti depressi hanno idee suicide

I pazienti depressi con aspetti psicotici considerano talvolta l’uccisione di persone coinvolte nei loro sistemi deliranti

Gender differences in health status

• In industrialized countries males tend to die earlier than females and females tend to have greater longevity but higher rates of morbidity (Okojie, 1994; Stein, 1997; Lewis, 1998)

• This female advantage is a relatively recent phenomenon and female excess mortality, which defined many western societies prior to the industrial revolution, still pertains in many less developed countries today ( Annandale, 1998)

Prevalenza della depressione(National Comorbidity Survey)

0

5

10

15

20

25

30

Infanzia15-24 25-34 35-44 45-54 55-64

Classi di Età (anni)

Percentuale di Casi

MaschiFemmine

Gender Differences in Prevalence of Major Depression

Women: 1.5-2.5 X rate relative to men during ages 15-54

Kessler et al (1993) Journal of Affective Disorders

The rate of MD for women rises dramatically above that for men

during and after puberty (with two peaks - childbearing years and

perimenopausal transition) and then actually falls after menopause

Puberal status, puberal timing,age, hormonal mechanisms (Angold)

Difficulties with self-image, temperament and early sexuality (Stattin and Magnusson)

New, hormonally driven needs for affiliation, difficulties with the transition to adolescence negative life events (Cyranowski)

Girls who lack healthy parental attachmentsanxious or inhibited temperament failed to develop good coping skills (Cyranowski)

Genetic loading negative life events (Silberg, Pickles, Rutter)

History of MD, traumatic experiences, genetic factors, temperament (Kendler)

Reproductive Hormones and Neurotransmitters

Effects of Estrogen

•Synapse formation

•Activates mature neuronal cells

•Increases sensory perception

•Increases cerebral perfusion

•Augments central nervous system

glucose use

•Alters pain pathways

Differences between Males and Females in Rates of Serotonin Synthesis in Human Brain

Nishizawa S, Benkelfat C, Young SN, et al.Proc Natl Acad Sci USA 1997; 94 (10): 5308-13

DEPRESSIONE NELLA DONNA

IPOTESI TEORICHE Fasi vitaFasi VitaFASI VITA Problemi Collegati

Concentrazioni basse o fluttuanti di ormoni serici

Pubertà-Fase PremestrualeGravidanza-Post PartumMenopausa

ContraccettiviFecondazione Assistita Aborto Terapia Ormonale Sosti. Gravi. Multi.

DevelopmentalLife Events-Stress-TraumaAmbiente Familiare

TemperamentoCambiamenti OrmonaliPredisposizione Genetica Pathways Depressione

Gender Differences in The Rates of Exposure to Stressful Life Events and Sensitivity to Their Depressogenic Effects

Stressful Life Events

AssaultDivorce or separationFinancial problemsHousing problemsIllnessJob lossLegal problemsLoss of confidantMarital problemsRobberyWork problems

Proximal network event:

Problems in getting alone

Crisis

Death

Illness

Distal network event:

Problems in getting alone

Death

IllnessKendler KS, et al., 2001

Gender Differences in The Rates of Exposure to Stressful Life Events and Sensitivity to Their Depressogenic Effects

Conclusion

Women reported more interpersonal whereas Men reported more legal and work -related stressful life events.

Most life event categories influenced the risk for major depression similarly in the two sexes

The greater prevalence of major depression in women versus men is due neither to differences in the rates of reported stressful life events nor to differential sensitivity to their pathogenic effect.

Kendler KS, et al., 2001

• Job loss,

• Legal problems,

• Robbery

• Work problems

• Housing problems,

• Loss of confidant,

• Problems getting along with and crises

involving individuals in their proximal

network

• Illness of an individual in their distal

network

No or inconsistent gender difference:financial or marital problems, illness, illness of individual in in one’s proximal network, and problems getting along with and death of an individual in one’s distal network Kendler KS, et al., 2001

Male preponderant: Female preponderant:

Gender and the Frequency of

Stressful Life Events

Gender and Sensitivity to

Depressogenic Effect of Stressful Life Events

• divorce or separation

• work problem

• problems getting along with and

• death of an individual in their

proximal network

No or inconsistent gender difference

across samples, no consistent and significant gender differences were

seen in the sensitivity to the remaining 15 event categoriesKendler KS, et al., 2001

Male-sensitive: Female-sensitive:

PREVALENCE OF MD IN WOMEN

Genetic Loading Vulnerability/Exposure to Stressful Life Events

HPGAxis

Neuromodulators

Life Cycle in Women

Puberty Menopause

Modulation Of The Neuroendocrine System by Fluctuating Gonadal Hormones

Psychological

Reproductive

Adolescence, Sexuality, Maternity, Lifestyle, “Empty-nest syndrome”

Longitudinal View of Depressive Illnesses Across

Women’s Lives

Menarche

Premenstruum

Pregnancy

Postpartum

Menopause

Depression as a function of reproductive related

transitions in women

Premestrual syndrome

Premestrual dysphoric disorder

Depression in pregnancy

Postpartun “blues”

Postpartum depression

Postpartum psychosis

Perimenopausal depression

Luteal phase of the menstrual cycle

Luteal phase of the menstrual cycle

Antepartum months

First 2 postpartum weeks

First postpartum month (up to first 3 pp. month)

First postpartum month, especially first 2 pp. weeks

5-7 years prior to menopause

Condition Reproductive Transition

POSTPARTUM DEPRESSION

Depression as a function of reproductive related

transitions in women

Premestrual syndrome

Premestrual dysphoric disorder

Depression in pregnancy

Postpartun “blues”

Postpartum depression

Postpartum psychosis

Perimenopausal depression

Up to 80% of naturally menstruating women

3%-8% of naturally menstruating women

No altered risks for MD. 20% of pregnant women may have minor depressive symptoms

50%-80% of postpartum women

10%-22% of postpartum women

0.1 % of postpartum women

exact frequency unknown due to sources of inconsistency across studies (i.e.definition of menopause status)

Condition Frequency

Postpartum Depression: what it’s not

Postpartum depression has been used as a catchall phrase for many disorders, but it’s important to differentiate it from other postpartum disorders:

• Maternity Blues

• Postpartum panic disorder

• Postpartum obsessive-compulsive disorder

• Postpartum bipolar II disorder

• Postpartum posttraumatic stress disorder

• Postpartum psychosis

(Beck, Cheryl Tatano DNSc, CNM, FAAN, American Journal of Nursing, 2006; 106 (5) 40-50)

Postpartum Depression: what it is

Depressed Mood or Loss of Interest or Pleasure with 5 or more of the

following symptoms for at least two week:

1) insomnia or hypersomnia, 2) psychomotor agitation or retardation, 3)

fatigue, 4) changes in appetite, 5) feelings of worthlessness or guilt, 6)

decreased concentration and suicidality.

Although the DSM-IV-TR states that the depressive episode begins within four weeks of birth, many clinicians and researchers agree that this description is too limiting, as it’s thought that postpartum depression can occur up to a year after childbirth.

Postpartum Depression is a major depressive disorder. It strikes about 1 in 10 women.

Premenstrual Dysphoric Disorder (PMDD)

Mood symptoms during past oral contraceptive use

A past history of depression

Mood symptoms during the first 2-4 days postpartum

Bloch M et al. J Affect Disord. 2005; 88 (1): 9-18.

RISK FACTORS Associated With The Development of Postpartum Mood Disorders

Were found to be significant risk factors for postpartum mood disorders:

Prenatal depression

Low self-esteem

Difficulties with child care

Prenatal anxiety

A high stress level

A low level of social support

Poor marital relationship

Two recent metaanalyses have identified significant risk factors for Postpartum Depression

Beck, Cheryl Tatano DNSc, CNM, FAAN, American Journal of Nursing, 2006

A history of depression

Difficult infant temperament

Maternity blues

Single marital status

Low socioeconomic status

Unplanned or unwanted pregnancy

POST PARTUM DEPRESSION

PMDDMood Symptoms During Past Oral Contraceptive

Use

A History of Depression

Low a low level of social support-socioeconomic status

Single marital status-Poor marital relationship

Maternity blues

Unplanned or unwanted pregnancy

Multiple BirthCesarean Surgery

Assisted Conception

Population projection of US adults with lifetime experience of depressive disorder by

age and sex from year 2005 to 2050 (III).

By year 2050, approximately 46 million US adults aged 18 years

Or older will be diagnosed with a depressive disorder. The increase

will be more pronounced in adults aged 65 or older. Prevention,

detection, and treatment of depressive disorders might attenuate

the magnitude of this estimate.

Heo M,, Murphy CF ET AL.Int J Geriatr Psychiatry. 2008 May 23. [Epub ahead of print]

CONCLUSIONS

??296.xx Disturbo Depressivo Maggiore296.xx Disturbo Depressivo Maggiore .2x Episodio Singolo .3x Ricorrente

300.4 Disturbo Distimico300.4 Disturbo Distimico

311 Disturbo Depressivo NAS311 Disturbo Depressivo NAS

Classificazione dei Disturbi dell’Umore secondo il DSM-IV TR

Il problema della diagnosi : Esiste una “Depressione dell’anziano” ?

LA PRESENTAZIONE CLINICA DELLA LA PRESENTAZIONE CLINICA DELLA DEPRESSIONE NELL’ANZIANODEPRESSIONE NELL’ANZIANO

Most common clinical featuresMost common clinical features

1. Una restrizione di competenze e abilità sociali, in seguito ad una crescente multi-morbidità, isolamento sociale, solitudine, perdita del partner e dei parenti, nelle sindromi depressive reattive” (Müller-Spahn et al, Gerontology 1994)

2. “Diffuse e mutevoli lamentele somatiche, ansia e agitazione psicomotoria nelle sindromi depressive endogene ” (Müller-Spahn et al, Gerontology 1994)

3. Comorbidità con disturbi d’ansia : disturbo di panico, fobie specifiche, fobia sociale (Lenze et al., Am J Psychiatry 2000)

LA PRESENTAZIONE CLINICA DELLA LA PRESENTAZIONE CLINICA DELLA DEPRESSIONE NELL’ANZIANODEPRESSIONE NELL’ANZIANO

Most common clinical featuresMost common clinical features

4) Hopelessness (Joiner et al, J Affect Disorder 2007)

4) Disforia e disturbi dell’appetito: sintomi prodromici : sintomi prodromici (Berger et al, Am J Psychiatry 1998)

6) Più lenta risposta agli antidepressivi (Mandelli et al, Psychiatry Res 2007)

PSEUDODEMENZA DEPRESSIVA vs ALZHEIMERPSEUDODEMENZA DEPRESSIVA vs ALZHEIMER

DATI ANAMNESTICIDATI ANAMNESTICI

Evoluzione lenta e progressivaEvoluzione lenta e progressiva

Nessuna storia significativa di Nessuna storia significativa di Depressione Depressione

Evoluzione piuttosto rapidaEvoluzione piuttosto rapida

Pregressi episodi di tipoPregressi episodi di tipodepressivo depressivo

Alzheimer DiseaseAlzheimer Disease Pseudodemenza DepressivaPseudodemenza Depressiva