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Psychological TheoryPsychological TheoryOfOf
DepressionDepression
:Uploaded By:
SAMIR KHAN
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Revolution in medicine !Revolution in medicine !
Vaccination Infectious
Antibiotics diseases
Change in life style Heart DiseasesStopping smoking &alcohol Diabetes mellitus
Use of exercise and yoga.
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A GENUINEA GENUINE
SMILE IS HARDSMILE IS HARD
TO FIND INTO FIND IN
THESE DAYSTHESE DAYS
FULL OFFULL OF
STRESSSTRESS
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WhatsWhats
wrongwrongwith her?with her?
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The Definition of HealthThe Definition of Health
Health is a state ofcomplete physical,mental, and social well-being, and notmerely the absence of disease or infirmity.
(Callahan 1973).
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BigBig
5.3% of general population
Every fourth women Every sixth or seventh men.
17 % of people in their lifetime.
30-50% with acute or chronic illness.
Every fourth patient repeatedly
visiting physician for similarcomplaints
Could Suffer from depression
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Recognised
depression
Depression unrecognised bydoctors
Depressed patients who do not seek
medical advice
ICEBERG OF DEPRESSION
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DEPRESSION
is depressed mood , for most
of the day nearly every day
( for at least two weeks )
with greatly diminished
pleasurein all activities .
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Death of a loved one
Divorce or breakup in a relationship
Unemployment
Financial problems
Unexpected medical illness
Loss of independence
Environmental factorsEnvironmental factors
Precipitate, do not causePrecipitate, do not cause
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Found in close blood relatives of
depressed patientsVarious regions on chromosome
18 and a site on chromosome 21
have been implicated.
Genetic FactorsGenetic Factors
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Defects in many neurotransmitters
in the CNS are linked to the
development of depression
e.g. Serotonin (5 HT) & Noradrenaline (NA)
Neurological FactorsNeurological Factors
Hyposerotoninergic state
Hyponoredrenergic state
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SerotoninSerotonin5HT5HT andand
NorepinephrineNorepinephrineNENE in the brainin the brain
LimbicSystem
Locus Ceruleus(NE Source)
PrefrontalCortex
Raphe Nuclei(5-HT source)
Cooper JR, Bloom FE. The Biochemical Basis of Neuropharmacology. 1996.
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Co-morbid DepressionCo-morbid Depression
Chronic illness like,
1. IHD.
2. Diabetes.
3. Epilepsy.
4. Thyroid problem
Alcohol and drugs Post partum
depression
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Common Symptoms ofCommon Symptoms of
DepressionDepression Sad mood Loss of interest or pleasure in activities
Fatigue / lack of energy
Low motivation / difficulty starting activities
Problems concentrating and thinking
Increased or decreased appetite & weight
Changes in pattern of sleep
Feeling worthless or guilty
Suicidal thoughts or plans
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Depression. Its not only a state of mind.Depression. Its not only a state of mind.
Reference: Adapted from
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.
Fourth Edition,Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489.
The symptoms of depressionEmotional Symptoms
Include:
Sadness
Loss of interest or pleasure
Overwhelmed
Anxiety
Diminished ability to think or
concentrate, indecisivenessExcessive or inappropriate guilt
Physical SymptomsInclude:
Vague aches and pains
Headache
Sleep disturbances
Fatigue
Back pain
Significant change in appetiteresulting in weight loss or gain
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The neurotransmitter pathway storyThe neurotransmitter pathway story
Adapted from References:
1. Stahl SM. J. Clin Psych. 2002;63:203-220.
2. Verma S, et al. Int Rev Psychiatry. 2000;12:103-114.3. Blier P, et al. J Psychiatry Neurosci. 2001;26(1):37-43.
Dysregulation of Serotonin (5HT) andNorepinephrine (NE) in the brain are stronglyassociated with depression
Dysregulation of 5HT and NE in the spinalcord may explain an increased pain
perception among depressed patients1-3
Imbalances of 5HT and NE may explain thepresence of both emotional and physicalsymptoms of depression.
Its not all in your head
Descending Pathway
Ascending
Pathway
Ascending
Pathway
Descending
Pathway
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How to diagnose ?How to diagnose ?
Q. 1 Do you feel sadness for most of theday,nearly every day past two weeks?
Q. 2 Have you lost interest or pleasure
in habitually pleasurable activities for
past two weeks?
Ask2 Questions !
No Depression !
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How to diagnose ?How to diagnose ?
Q. 1 Do you feel sadness for most of theday,nearly every day past two weeks?
Q. 2 Have you lost interest or pleasure
in habitually pleasurable activities for
past two weeks?
Ask2 Questions !
Strongly indicates depression!
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What else to look for ?What else to look for ?
Sleep : insomnia or hypersomnia
Appetite : Change in appetite leading to
weight loss or weight gain.
Activities : Slow or Agitated (restless).
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What else..?What else..?
Fatigue / Lack of energy.
Concentration difficulties,
forgetfulness
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What else..?What else..?
Feeling of worthlessness.
Excessive of inappropriate guilt.
Recurrent thoughts of death andsuicide.
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What to look for ?What to look for ?
Irritability.
Psychomotor retardation / Slow
activities.
Downward gaze.
Tearful affect.
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When will you suspect ?When will you suspect ?
Any patient ( female ) with no medical
illness coming with pain,headache,
insomnia, fatigue, anxiety.Any patient with pain at more than 2 sites.
Old patients where symptoms are
disproportionate to the physical illness.Any patient with long standing illness.
Like HT, IHD, Diabetes,Epilepsy.
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Difference Between Normal andDifference Between Normal and
Real DepressionReal Depression
Normal Depression
Normal reaction to lifeevents (e.g. death of lovedone, major changes)
Mood described as blue
Few symptomsShort duration
Little, if any, impairmentin functioning
Mood
Clinical Depression
Mood described as black
Many symptoms Longer duration (weeks months) Significant impairment in
functioning (can be debilitating)
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Increased morbidity and mortality.
Disrupts marital, familial, social life.Affects work, leads to job related problems.
Increased incidence of medical
illnesses,accidents.Risk of suicide.
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What shall I do ?What shall I do ?
Non drug treatment:
Counseling.Psychotherapy.
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What should I use?What should I use?
Once a diagnosis of depression has
been made, an anti-depressant should
be started, no matter what the cause of
the depression.
All Antidepressants are effective, butdiffer in their side effect profile.
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In any case, Reversal of DepressionIn any case, Reversal of Depression
Should be possible byShould be possible by
IncreasingIncreasing
5HT5HT NANACNS Neuronal TransmissionCNS Neuronal Transmission
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Anti-depressantsAnti-depressants1. Tricyclics : Imipramine, Amytriptyline, Clomipramine, Dothiepin, Doxepin,
Nortriptyline.
2. Tetracyclics : Amoxapine, Mianserin
3. Specific Serotonin Reuptake Inhibitors (SSRIs) : Fluoxetine, Sertraline,Fluvoxamine, Paroxetine, Citalopram.
4. Serotonin Antagonists & Reuptake Inhibitors : Trazodone
5. Serotonin & Noradrenaline Reuptake Inhibitors : Venlafaxine
6. Reversible Inhibitors of Monoamine Oxidase : Moclobemide
7. Noradrenaline & Specific Serotonin Anti-depressant : Mirtazapine
8. Noradrenaline & Dopamine Reuptake inhibitor : Bupropion, Tianeptine
9. Noradrenaline reuptake Inhibitors: Reboxetine
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Drug Treatment.Drug Treatment.
Older drugs: Amitriptyline,Imipramine.
Both 75 to 150 mgin daily divided doses.
Still used as effective drugs.Side effects like sedation,hypotension,constipation, urinary
retention.
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Drug Treatment.Drug Treatment.
Newer drugs: Treatment of Choice.
Escitalopram ( 5 to 10 mg OD)
Sertraline (25 to 150 mg OD).
Well tolerated.
Few side effects like headache , anxiety, sexual
side effects.Duration : 6 9 months.
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Know this too !Know this too !
Electro-convulsive therapy ( Shock
treatment) forseverely depressed andsuicidal patient
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The mind is its own place, and in itself
Can make a Heavn of Hell, a Hell of Heavn.
John Milton 1608-74
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SPREAD ASPREAD A
SMILESMILE
IT CAN MAKEIT CAN MAKE
A WORLD OFA WORLD OF
DIFFERENCEDIFFERENCE
THANKTHANKYOUYOUSAMIR KHAN