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Liaquat National Hospital

Department of Psychiatry

Turning Disabilities Into Possibilities


DEPRESSION
There are at least
two sides to every
story….

Presented by
Dr Sana Abubakar
Resident Psychiatry
Department
Liaquat National Hospital
CASE SUMMARY
A 39 year old married female, project
coordinator at Pakistan International
Airlines came with epigastric pain,
vertigo and palpitations. She was
referred to Psychiatry having found to
have no medical causes of her
CASE SUMMARY
Her Interview revealed following:

 Symptoms began 15 yrs back and have been increasing in severity.

 She was being treated for peptic ulcer every time she had these symptoms.

 There have been several admissions previously. All admissions were due to
epigastric pain and weakness.She doesn’t like to eat and has always been under
weight

 She was a playful child. During her adolescence she became too dependent on
friends. She quit her admission in medical college and accompanied her school friend
to an arts college.

 This display of dependence prompted her father to get her involved in a small job in
PIA at the age of 18 yrs. She is working in the same organization till date with
several increments and promotions. She also completed her bachelors during early
days of work.

 She is married for 16yrs now. Her marriage is “normal” according to her. She has
three children. Daughter 15 yrs, son 13 yrs and son 10 yrs old. Her children are too
sensitive and scared for her when she falls ill.

 She also took several loans from her company to build her own house. A major
portion of her salary is spent on clearing debts. But I am not worried about it, she
says.
CASE SUMMARY
 Her husband’s brother and his family share the house without paying any rent,
because they are helping her raise her children. She is a working woman and
according to her not fit to take care of the house.

 She understands that her children face a lot of criticism and hard time due to
involvement of the other family but she is not worried about that too.

 Her parents and are very supportive. “They come running for me when I am
sick”. My father loves me the most among all siblings. She is the second child.
Her elder brother is on anti depressants. One brother recently had a divorce and
had to leave her daughter in Holland. She is not worried about that too.

 Her father is alive and healthy. Mother died of cardiac arrest one year back
during the period of her son’s divorce.

 When asked about her own idea of her situation she says “ I am responsible for
every thing. Every thing is perfect, every one loves me, I am blessed still I am
unthankful and I am the source of worry for people who love me.”
CASE SUMMARY
Her mental state examination reveals
 A middle aged female passes a smile as I enter. She
maintains an eye contact and communicates
comfortably. She accompanied by brother who tries to
answer all her questions and treats her like a kid.

 Mood is normal

 Thought contents are those showing excessive guilt and


dependence.
 Diagnosis?
 Etiology?
 Treatment?
DEPRESSIVE DISORDERS
 Classified under mood disorders.

 Central features are:


 Depressed mood
 Negative thinking
 Lack of enjoyment
 Reduced energy
 slowness
DEPRESSIVE EPISODE ACCORDING TO ICD-10

A: Depressed mood
Loss of interest
Reduced energy and decreased activity

B: Reduced concentration
Reduced self esteem and confidence
Ideas of guilt and worthlessness
Pessimistic thoughts
Idea of self harm
Disturbed sleep
Diminished

 
DEPRESSIVE EPISODE ACCORDING TO ICD-10

 Mild: 2A and 2B

 Moderate: 2A and 3B

 Severe: 3A and 4B
DSM-IV-TR Criteria for Major
Depressive Episode
 Five (or more) of the following symptoms have been present during the
same 2-week period and represent a change from previous functioning; at
least one of the symptoms is either (1) depressed mood or (2) loss of
interest or pleasure.
 Note: Do not include symptoms that are clearly due to a general medical
condition, or mood-incongruent delusions or hallucinations.

 depressed mood most of the day, nearly every day, as indicated by


either subjective report (e.g., feels sad or empty) or observation made
by others (e.g., appears tearful). Note: In children and adolescents,
can be irritable mood

 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 made by others)
DSM-IV-TR Criteria for
Major Depressive Episode
 significant weight loss when not dieting or
weight gain (e.g., a change of more than 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 gains.
 insomnia or hypersomnia nearly every day
 psychomotor agitation or retardation nearly
every day (observable by others, not merely
subjective feelings of restlessness or being
slowed down)
DSM-IV-TR Criteria for Major
Depressive Episode
 fatigue or loss of energy nearly every day

 feelings of worthlessness or excessive or inappropriate guilt


(which may be delusional) nearly every day (not merely self-
reproach or guilt about being sick)

 diminished ability to think or concentrate, or indecisiveness,


nearly every day (either by subjective account or as
observed by others)

 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
DSM-IV-TR Criteria for Major
Depressive Episode
 The symptoms do not meet criteria for a mixed episode.

 The symptoms cause clinically significant distress or impairment in


social, occupational, or other important areas of functioning.

 The symptoms are not due to the direct physiological effects of a


substance (e.g., a drug of abuse, a medication) or a general medical
condition (e.g., hypothyroidism).

 The symptoms are not better accounted for by bereavement, i.e.,


after the loss of a loved one, the symptoms persist for longer than 2
months or are characterized by marked functional impairment,
morbid preoccupation with worthlessness, suicidal ideation,
psychotic symptoms, or psychomotor retardation.
Some other forms of
depression
 MELANCHOLIC DEPRESSION
 PSYCHOTIC DEPRESSION
 AGITATED DEPRESSION
 RETARTED DEPRESSION
 DEPRESSIVE STUPOR
 ATYPICAL DEPRESSION
 MINOR DEPRESSIVE DISORDER OR
MIXED ANXIETY AND DEPRESSION
Clinical features of
melancholic depression
 At least one of the following:

 Loss of pleasure (anhedonia) in all, or almost all, activities

 Lack of mood reactivity to usually pleasurable stimuli (can't feel much better, even when
something good happens)

 At least three of the following:

 Distinct quality of depressed mood (i.e., the depressed mood experienced is distinctly
different from the kind of feeling experienced after the death of a loved one)

 Depression is regularly worse in the morning

 Early morning awakening (at least 2 hours before usual time of awakening)

 Marked psychomotor retardation or agitation

 Significant anorexia or weight loss

 Excessive or inappropriate guilt


Depression – the physical
presentation
In primary care, physical symptoms are often
the chief complaint in depressed patients

In a New England Journal of Medicine


study, 69% of diagnosed depressed
patients reported unexplained physical
symptoms as their chief compliant1

N = 1146 Primary care patients with major depression


Aches/pain – a physical
symptom of significance
Aches/Pain as common as anxiety among depressed patients
70 National Comorbidity
Survey
60 58%
55%
% of Depressed Patients

NIMH Epidemiology
50 Study

40 38% 37%
35%

30 28%
25%

20 17%

10

0
Aches/Pain Aches/Pain Anxiety Disorder Anxiety Disorder
(Women) (Men) (Women) (Men)
Differential diagnosis

 Bipolar affective disorder


 Normal Sadness
 Anxiety disorders
 Schizophrenia
 Organic brain syndrom
A SYSTEMATIC SCHEME FOR
CLINICAL DESCRIPTION OF
DEPRESSIVE DISORDER

 The episode

Severity
Type
Special features
Course
Aetiological factor
Etiology – Psychological models

• Psychodynamic – fixation at oral stage


• mourning and melancholia – introjection
of lost loved one, anger turned inwards
• Depressive personality
• Attachment – Bowlby, anaclitic
depression, introjective depression
Etiology – Psychological models

• Cognitive – Beck – negative cognitive


triad
• negative schemata
• cognitive distortions – selective
abstraction, arbitrary inference,
overgeneralization, magnification and
minimization
Etiology – Psychological models
•Learned helplessness and causal
attributions – Seligman
• Life stress – especially loss experiences
• Interpersonal effects – marital violence,
expressed emotion (EE)
• 3 components of EE – criticism, hostility,
over involvement
Etiology – Biological models

•Genetics – first degree relatives of people


with unipolar disorder have 30-35%
prevalence rate for depression; second
degree relatives, 12-15% prevalence rate
• Twin study (Mc Guffin et al., 1991) –
Concordance rates of 53% for MZ twins,
28% for DZ for unipolar disorder
Etiology – Biological models

•Twin study
•Neurotransmitter deficiencies –
catecholamine (NE and serotonin)
• Monoamine hypothesis – shortage of NE,
dopamine, and serotonin
Etiology – Biological models

•EEG findings – higher alpha readings in


left front region
• Sleep disturbances – decrease in slow
wave sleep and earlier onset of REM
• MRI and PET studies show increased
ventricle size and decreased activity in left
lateral prefrontal cortex
Serotonin5HT and
NorepinephrineNE in the
brain
Limbic System
Prefrontal
Cortex

Locus Ceruleus
Raphe Nuclei (NE Source)
(5-HT source)

Cooper JR, Bloom FE. The Biochemical Basis of Neuropharmacology. 1996.


There are at least two
sides to the
neurotransmitter story
Functional domains of Serotonin and Norepinephrine 1-4

Serotonin (5-HT) Depressed


Norepinephrine (NE)
Mood

Sex Anxiety Concentration

Vague Aches
Appetite Interest
and pain

Aggression Irritability Motivation

Thought
process

• Both serotonin and norepinephrine


mediate a broad spectrum of
depressive symptoms
The neurotransmitter
pathway story
It’s not all in your head

 Dysregulation of Serotonin
(5HT) and Norepinephrine (NE)
in the brain are strongly
associated with depression

Descending Pathway
 Dysregulation of 5HT and NE in
Descending
the spinal cord may explain an Pathway Ascending
increased pain perception
Pathway
among depressed patients1-3

 Imbalances of 5HT and NE may


explain the presence of both
emotional and physical Ascending
symptoms of depression. Pathway
Treatment – Psychological models

•Depression often improves without


treatment
• Cognitive therapy
• Behavioral strategies
• Interpersonal therapy
Treatment – Biological models

Antidepressant therapy – MAOs, tricyclics,


selective serotonin reuptake inhibitors (SSRIs)
Combining pharmacotherapy and psychological
therapy
 ECT – a controversial treatment
CLINICAL CHARACTERISTICS OF
SOME ANTI DEPRESSANTS
Anticholinergic Sedation Weight Sex dysfunction Toxicity

Amitriptyline +++ +++ +++ + +++

Lofepramine + 0 0 + 0

SSRIs 0 0 + +++ 0

Venlafaxime 0 0 + +++ ++

Duloxetine 0 0 + +++ ?

Trazodone 0 +++ + 0 +

Reboxetine + 0 0 + 0

Mirtazapine 0 +++ +++ 0 0


ADVERSE PROGNOSTIC
FACTORS
 INCOMPLETE SYMPTOMATIC REMISSION
 EARLY AGE OF ONSET
 POOR SOCIAL SUPPORT
 POOR PHYSICAL HEALTH
 CO MORBID SUBSTANCE ABUSE
 COMORBID PERSONALITY DISORDER