DEPRESSIVEDISORDERS

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

SADvs

DEPRESSED

Depression:Common Symptoms

MOOD PSYCHOLOGICAL PHYSICAL

Prolonged unhappiness

Loss of interest or pleasure

Hopeless

Helpless

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 malesHormonal, differing psychosocial stressor and

learned helplessness Learned helplessnessDiffering psychosicial stressors

Highest rates between 25 - 44 years old

Increasing in people less than 20 years old

4

Genetic Factors10 25% risk for a child if one parent has mood

disorder1.5 - 3x greater risk in patients with a (+) family

history.Herditability is about 40-50% specially in severe

depressionMonozygotic or identical twins double risk vs

dizygotic or fraternal twin studies

5

Psychosocial Factors such as Life events and Environmental Stress

Losing a parent before the age of 11 Loss of spouseUnemploymentRecent life events are the most powerful

predictors of the onset of a depressive episode

6

Diathesis model Individual vulnerability

Cognitive theory (triad of depression)1. view about self (negative self-percept)2. about the environment (hostile and

demanding world)3. about the future (suffering and failure)

7

Biologic factorsProbable cause: depletion of serotonin and

noradrenaline at the synapses In relation to genetics, one gene isolated 5HTT

which helps regulate neurotransmitter -Serotonin

8

Biochemical Basis of Depression

The Amine Hypothesis:

Depression arises as a consequence of adisturbance of one or more of the biogenicamine neurotransmitters in the brain. This formsthe basis of the monoamine hypothesis ofdepression, which suggests that a relative deficitin NA, 5HT and DA is responsible for thesymptoms of depression.

Biochemical Basis of Depression

The amine hypothesis postulates that thechanges in mood (possibly linked to a deficitin 5-HT), deficit in drive and motivation(possibly linked to DA and NE) are the resultsof hypoactivity of these neurotransmitters.

The Amine Hypothesis

Antidepressants act on various biochemicalprocesses in the brain by which the amineneurotransmitters prolong their physiologicactions and thereby attenuate the mainsymptoms of depression.

Neurotransmitters and Clinical Symptoms

NORADRENALIN

DOPAMINE

SEROTONIN

APATHY

LACK OF

INTEREST

TENSE

IRRITABLE

LACK OF

PLEASURE

ANXIETY

MOOD

THOUGHTS

LACK OF

ENERGY

APPETITE

SEX

The Role of Noradrenalin

There is accumulating evidence that the NA systemmodulates drive and motivation, aside fromlearning and memory

Noradrenergic Pathways

The Role of Serotonin

The serotonergic system modulates impulsivenessand 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 nearlyeveryday

Insomnia and fatigue- usual presentingcomplaint

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

Depression in Primary Care Setting

Neurotransmitters and Clinical Symptoms

NORADRENALIN

DOPAMINE

SEROTONIN

APATHY

LACK OF

INTEREST

TENSE

IRRITABLE

LACK OF

PLEASURE

ANXIETY

MOOD

THOUGHTS

LACK OF

ENERGY

APPETITE

SEX

Major Depressive Disorder:

DSM Criteria

A. 5 or more of the following symptom

2-week period either depressed mood or loss of interest

1. Sad, depressed mood, most of the day, nearly every day for two weeks

2. Loss of interest and pleasure in usual activities3. Difficulties sleeping4. Shift in activity level 5. Changes in appetite and weight loss/gain6. Loss of energy, fatigue7. Negative self-concept, self-blame, guilt, worthlessness8. Difficulty concentrating 9. 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 angryor 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 haspersisted 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

Essential expression of mood la bility

Irritability

dysphoria,

anxiety

symptoms that occur repeatedly during the pre menstrual phase

Premenstrual Dysphoric Disorder

Premenstrual Dysphoric Disorder

A. In the majority of menstrual cycles, at least 5symptoms must be present in the final weekbefore the onset of menses, start to improvewithin a few days after the onset of menses, andbecome minimal or absent in the weekpostmenses

B. 1 or more of the following symptoms must be present:

Marked affective labilityMarked irritability or anger or increased

interpersonal conflictsMarked depressed mood, feelings of

hopelessnessMarked 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. Decreased interest in usual activities

2. Subjective difficulty in concentration

3. Lethargy, easy fatigability, or marked lack of energy

4. Marked changes in appetite; overeating;

5. Hypersomnia or insomnia

6. Sense of being overwhelmed or out of control

7. 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 clinicallysignificant distress or interference with work, school,usual social activities, or relationships with others

E. The disturbance is not merely an exacerbation ofthe symptoms of another disorder, such as majordepressive disorder, panic disorder, persistentdepressive disorder (dysthymia), or a personalitydisorder (although it may co-occur with any of thesedisorders).

F. Criterion A should be confirmed by prospectivedaily ratings during at least two symptomatic cycles.(Note: The diagnosis may be made provisionallyprior to this confirmation.)

G. The symptoms are not attributable to thephysiological effects of a substance or anothermedical 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 bydepressed 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 orafter exposure to a medicationThe 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 acutewithdrawal or severe intoxication

Substance/Medication-Induced Depressive Disorder

E.The disturbance does not occur exclusivelyduring the course of a delirium

The disturbance causes clinically significantdistress or impairment in social,occupational, or other important areas offunctioning

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 pleasurein all, or almost all, activities that predominates inthe clinical picture

B.There is evidence from the history, physical

examination, or laboratory findings that thedisturbance is the direct pathophysiologicalconsequence 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, withdepressed mood, in which the stressor is a seriousmedical 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

Depressive Disorder Due to Another Medical Condition

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

Serotonin-norepinephrine reuptake inhibitors

Serotonin-2 antogonism/reuptake inhibitors

2 antagonism + serotonin reuptake inhibition

Selective norepinephrine and dopamine reuptake inhibitors

SummaryMany of the side effects of antidepressants are

attributable to the action of the drug on receptorsthat are associated with their antidepressantactions (such as the adrenoreceptors, muscarinicreceptor and histaminic receptors).

Some side effects are an inevitable consequence ofactivation of the serotonergic system and includethe neurological, sexual, and GI side effects. Sucheffects 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!