Depression

1. Depression
Dr. Mustafa Abdirahman (Munshawi)
Mmed Psychiatry

2. The central features of depressive disorder are:
 Depressed mood
 Negative thinking
 Lack of enjoyment
 Reduced energy
 Slowness.

4. Depressive cognitions
Negative thoughts (‘depressive cognitions’) are important
symptoms that can be divided into three groups:
 worthlessness
 pessimism
 guilt.

5. Goal-directed behaviour
 Lack of interest and enjoyment (also known as anhedonia) is
frequent, although it is not always complained of
spontaneously. Patients show no enthusiasm for activities and
hobbies that they would normally enjoy.
 Patients feel lethargic, find everything an effort, and leave
tasks unfinished.
 Psychomotor retardation is frequent, patient walks and acts
slowly. Slowing of thought is reflected in their speech; there is
a significant delay before questions are answered, and pauses
in conversation may be unusually prolonged.

6. Biological symptoms
 There is an important group of symptoms that is often
described as ‘biological’ These symptoms include sleep
disturbance, diurnal variation in mood, loss of appetite, loss of
weight, constipation, loss of libido, and, among women,
amenorrhoea.

7. Classification by symptomatic picture
1. Melancholic depression
2. Psychotic depression
3. Seasonal affective disorder
4. Atypical depression

8. Psychotic depression
 As depressive disorders become increasingly severe, all of the features
described above occur with greater intensity.
 There is complete loss of function in social and occupational spheres.
 In addition, there may be delusions and hallucinations,
 Inattention to basic hygiene and nutrition may give rise to concern about
the patient’s wellbeing.

9. Atypical depression
 variably depressed mood with mood reactivity to positive events
 overeating and oversleeping
 extreme fatigue and heaviness in the limbs (leaden paralysis)
 pronounced anxiety.

10. Transcultural factors
 There are cultural variations in the clinical presentation of
depressive states, but in most countries depression appears to
be underdiagnosed, particularly in primary care. In fact,
sadness, joylessness, anxiety, and lack of energy are common
symptoms of depression in most
 While somatic presentations of depression are undoubtedly
found in all societies, they are apparently more frequent and
prominent in non-western cultures,

11. Epidemiology
 The 12-month prevalence of major depression in the
community is around 2–5%.
 The mean age of onset is about 27 years.
 Rates of major depression are about twice as high in women
as in men, across different cultures.
 Rates of depression are higher in the unemployed and
divorced.

12. Etiology
 The exact cause of depression is unknown, but biological, genetic, environmental, and
psychosocial factors each contribute.
 The leading theory is that depression is caused by neurotransmitter deficiencies in the
brain
 Decreased levels of serotonin and its metabolite (5-HIAA), are found in depressed
patients.
 Drugs that increase availability of serotonin, norepinephrine, and dopamine often
alleviate symptoms of depression.
 High cortisol: Hyperactivity of hypothalamic-pituitary-adrenal axis as shown by failure
to suppress cortisol levels in dexamethasone suppression test.
 Genetics: First-degree relatives are two to three times more likely to have MDD.
Concordance rate for monozygotic twins is about 50-70%, and 10-25% for dizygotic
twins.

13. Cognitive theories
Depressed patients characteristically have recurrent and intrusive negative thoughts
(‘automatic thoughts’).
 Arbitrary inference (drawing a conclusion when there is no evidence for it and even
some evidence against it).
 Selective abstraction (focusing on a detail and ignoring more important features of a
situation).
 Overgeneralization (drawing a general conclusion on the basis of a single incident).
 Personalization (relating external events to oneself in an unwarranted way).

14. Endocrine pathology and depression
 About 50% of patients with Cushing’s syndrome suf-fer from major depression,
which usually remits when the cortisol hypersecretion is corrected. Depression also
occurs in Addison’s disease, hypothyroidism, and hyperparathyroidism.
 Endocrine changes may account for depressive disorders that occur premenstrually,

15. COURSE
 If left untreated, depressive episodes are self-limiting but usually last from
6 to 13 months.
 Generally, episodes occur more frequently as the disorder progresses. The
risk of a subsequent major depressive episode is 50% within first 2 years
 About 15% of patients eventually commit suicide.

16. Management
1. Antidepressants
2. Psychotherapy
3. ECT/TMS

17. Antidepressants
 Different types of depression
 Enuresis (with or without behaviour therapy)
 Attention deficit disorder with hyperactivity (in low doses, after 6 years of
age, when stimulant medication is not available)
 School phobia (sometimes, in low doses)
 Separation anxiety disorder (in children)
 Somnambulism
 Night terrors

18.  Panic attacks (e.g. SSRIs)
 Agoraphobia and social phobia
 Obsessive compulsive disorder with or without
 depression (e.g. clomipramine, SSRIs)
 Cataplexy (associated with narcolepsy)
 Aggression in elderly (e.g. trazodone)
 Eating disorders (e.g. fluoxetine in bulimia nervosa)
 Borderline personality disorder
 Trichotillomania

19.  Post-traumatic stress disorder (PTSD)
 Generalized anxiety disorder (e.g. SSRIs)
 Nicotine dependence (e.g. bupropion is used for treatment of craving)
 Alcohol dependence (e.g. fluoxetine sometimes used for treatment of craving)
 Chronic pain (in low doses, e.g. amitriptyline, duloxetine)
 Migraine (as an adjuvant)

20. Classification of Antidepressants
1. Tricyclic antidepressants
(Amitriptyline, Clomipramine, Imipramine, Doxpine)
2. Selective Serotonin Reuptake Inhibitors (SSRIs)
(Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline)
3. Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
(Venlafaxine, Duloxetine)
4. Noradrenergic and Specific Serotonergic Antagonists (NaSSAs)
Mirtazapine
5. Norepinephrine Dopamine Reuptake Inhibitors (NDRIs)
Bupropion

21. 6. Serotonin Antagonists and Reuptake Inhibitors (SARIs)
Nefazodone, Trazadone
7. Mono-amine Oxidase Inhibitors (MAOIs)
Selegiline, Moclobemide
8. Melatonin receptor agonist and 5-HT2C antagonist
Agomelatine

22. TCAs
 Inhibit the reuptake of norepinephrine and serotonin, it
increases availability of monoamines in the synapse.
Because of the long half-lives, most are dosed once daily.
They are rarely used as first-line agents because they have a
higher incidence of side effects, require greater monitoring of
dosing, and can be lethal in overdose.

23. Serotonin syndrome
 A number of drugs that potentiate brain 5-HT function can produce a severe
neurotoxicity syndrome when combined with MAOIs.