Depression major depressive disorder Oldest recognized disorder: melancholia It is a positive and active anguish, a sort of psychical neuralgia wholly unknown to normal life. - William James "I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would be not one cheerful face on earth. - Abraham Lincoln, 1841 Some terms: Affect refers to the expression of emotion. Mood refers to a prolonged emotion that colors the whole psychic life; when it is disturbed, it can involve excessive depression or elation (or both). Depressive disorders involve states of persistent negative mood of sufficient intensity to be maladaptive. Bipolar disorders involve states of persistent positive and negative mood of sufficient intensity to be maladaptive. At least five of the following symptoms, for at least two weeks, representing a change from previous functioning: depressed mood* markedly diminished interest or pleasure in usual activities* (anhedonia) *at least one of the symptoms is one of these continued: significant weight or appetite change insomnia or hypersomnia psychomotor agitation or retardation fatigue feelings of worthlessness or excessive guilt diminished ability to think or concentrate recurrent thoughts of death, recurrent suicidal ideation or a suicide attempt
comment: note that the syndrome has significant negativity with emotional Sx motivation behavioral Sx cognitive Sx physical Sx Stress and loss play significant roles in onset and maintenance of the Sx ICD: In typical mild, moderate, or severe depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called "somatic" symptoms, such as loss of interest and pleasurable feelings, waking in the morning several hours before the usual time, depression worst in the morning, marked psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido. Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe. DSM and ICD have sub-types and specifiers by severity recurrence presence of anxiety, mood incongruence, anxiety, psychosis, catatonia and other features peripartum onset seasonal The depressive disorders the case of Anne (video)
Other depressive disorders Persistent Depressive Disorder (Dysthymia) chronic 2+years of two or more Sx of a depressive episode (person may have Major depression, but must Sx must be continuous, no relief for more than 2 months) Substance- or Medication-induced Depressive Disorder Premenstrual dysphoric disorder five Sx during the premenstrual period not evident at other times most cycles for over a year Disruptive Mood Dysregulation (children) severe, grossly disproportionate, and frequent temper outbursts, inconsistent with developmental level, present for over a year (controversial) Major Depressive Disorder vs. gender dysphoria a notable omission is the lack of a specifier for dysphoria related to problems with gender identity despite extensive research that suggests a high rate of depression in gender minorities, particularly in adolescence the DSM reserves gender dysphoria in a separate chapter associated with sexual disorders; ICD includes it under Disorders of adult personality and behaviour Incidence of major depression 12-month prevalence of any affective disorder is about 10%, life-time prevalence is about 20% (NCS). Incidence rate for depression is about twice as common for females than males. Severe stress is often a precipitant/concomitant occurrence with the onset of mood disorders. The most common stressor is loss, particularly loss of a loved one. a common situation is social isolation and loneliness thus social skills become an important area of intervention. another common cause is loss of function or disability Medications for depression Adrenergic and serotonergic depressions Antidepressants and the advent of inhibiting medications TCAs: tricyclics clomipramine (Anafranil) MAOIs: monoamine oxidase inhibitors isocarboxazid (Marplan) SSRIs: Selective serotonin inhibitors fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft) SNRIs: serotonin and norepinephrine inhibitors venlafaxine (Effexor) aminoketones: "atypical antidepressants that have a poorly understood MOA; have dual role of blocking dopamine and norepinephrine bupropion (Wellbutrin)
Medications for depression Transmission site Almost all axons and nerve endings regulate neurotransmission by metabolizing or reabsorbing excess neurotransmitter in the synaptic cleft. This is called - usually occurs at specific sites (but not always) Metabolic action Reuptake medications such as tricyclics and MAOI s reduce acids that metabolize neurotransmitters prior to crossing the synaptic cleft (thereby reducing and increasing neurotransmission). Tricyclics also reduce ACH activity. Reuptake medications such as SSRI s reduce or block the activity of sites or vesicles
SSRI s are selective.. Because sites vary in neurons Because the medication can vary in its effectiveness in different sites one notable aspect about SSRIs is that they have a delayed behavioral and emotional effect of 1 to 4 weeks after optimal blood levels have been attained The delayed learning effect controversies: Prozac, Lexapro and the SSRIs SSRIs are extensively used, prescribed by general practitioners as well as psychiatrists. Tony (and most medical ethicists): the controversy should be personal. As with any medication, the decision to use or not use antidepressant medication requires personal and well-informed decisionmaking. Facts: Psychosocial perspectives on depression The most common event that relieves depressive symptoms is falling in love/developing new intimate relationship(s). The next most common is getting or regaining vocational activity
Psychosocial perspectives on depression Behavioral perspective: Low reward, poor social competence (Lewinsohn) Learned helplessness (Seligman) Interpersonal and social skills deficits Inner turmoil and mindfulness Self-efficacy (Bandura) Becks cognitive-behavioral theory and CBT Conclusion Depression as existential challenge to our lives the specter of suicidality