MAJOR DEPRESSIVE

DISORDER
Presented by:
Justin Darrell A. SALACUP
Major Depressive Disorder
• The diagnosis of MDD or major depression is based on the occurrence
of at least ONE MAJOR DEPRESSIVE EPISODE in the absence of a
history of mania or hypomania
• A major depressive episode must last at least 2 weeks
• Experiences at least four symptoms from a list that includes changes
in appetite and weight, changes in sleep and activity, lack of energy,
feelings of guilt, problems thinking and making decisions, and
recurring thoughts of death or suicide.
Epidemiology
• Leading cause of disability among adults <45 y/o
• Lifetime prevalence of 12% in ♂, 20% in ♀
• Relative risk of 2-3 in 1o relatives of probands
• 41%:13% (monozygotic:dizygotic) concordance
• Incidence peaks in 20s (but onset in late life is common)
• Elderly with medical problems- possible depression
Etiology
• Biological Factors
ØBiogenic amines
Ø Second Messengers and Intracellular Cascades
Ø Alterations of Hormonal Regulation
Ø Alterations of Sleep Neurophysiology
Ø Immunological Disturbance
Ø Structural and Functional Brain Imaging
Ø Neuroanatomical Considerations
Etiology
• Genetic Factors
• Psychosocial Factors
ØLife Events and Environmental Stress
ØPersonality Factors
ØPsychodynamic Factors in Depression
• Other Formulations of Depression
ØCognitive Theory
ØLearned Helplessness
Common Features of Depression
• Changes in Emotional States
ØChanges in mood (persistent periods of feeling down, depressed, sad, or blue)
ØEvidence of tearfulness or crying
ØIncreased irritability, jumpiness, or loss of temper
• Changes in motivation
ØFeeling unmotivated, or having difficulty getting going in the morning or even
getting out of bed.
ØReduced level of social participation or interest in social activities
ØLoss of enjoyment or interest in pleasurable activities
ØReduced interest in sex
ØFailure to respond to praise or rewards
Common Features of Depression
• Changes in functioning and motor behaviour
ØMoving about or talking more slowly than usual
ØChanges in sleep habits (sleeping too much or too little, awakening earlier than usual
and having trouble getting back to sleep in early morning awakening)
ØChanges in apetite (too much or too little) Changes in weight (gaining or losing)
ØFunctioning less effectively at work or school; failing to meet responsibilities and
neglecting one’s physical appearance.
• Cognitive changes
ØDifficulty concentrating or thinking clearly
ØThinking negatively about oneself and one’s future
ØFeeling guilty or remorseful about past misdeeds
ØLack of self – esteem or feelings of inadequacy
ØThinking of dead or suicide.
Specifiers (Symptom Features)
• Psychotic Features
ØReflects severe disease and is a poor prognostic indicator
ØPresence of psychotic features also has significant treatment implications
• Melancholic Features
ØCharacterized by severe anhedonia, early morning awakening, weight loss,
and profound feelings of guilt (often over trivial events).
ØChanges in the autonomic nervous system and in endocrine functions
Ø"endogenous depression"
Specifiers (Symptom Features)
• Atypical Features
ØPredictable characteristics: overeating and oversleeping
ØSymptoms have sometimes been referred to as reversed vegetative symptoms, and
the symptom pattern has sometimes been called hysteroid dysphoria
ØYounger age of onset; more severe psychomotor slowing; and more frequent
coexisting diagnoses of panic disorder, substance abuse or dependence, and
somatization disorder
• Catatonic Features
ØHallmark symptoms of catatonia- stuporousness, blunted affect, extreme withdrawal,
negativism, and marked psychomotor retardation
• Postpartum Onset
ØOnset of symptoms is within 4 weeks postpartum
DSM-5 Criteria for Diagnosing Major
Depressive Disorder
A. 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 attributable to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective
report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears
tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, o r almost all, activities most of the
day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change or more than
5°/o of body weight i n a month), or decrease or increase in appetite nearly every day.
(Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day
DSM-5 Criteria for Diagnosing Major
Depressive Disorder
5. Psychomotor agitation o r retardation nearly every day (observable by
others, not merely subjective feelings o r restlessness o r being slowed
down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may
be delusional) nearly every day (not merely self-reproach or guilt about
being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every
day (either by subjective account or as observed by others).
9. 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-5 Criteria for Diagnosing Major
Depressive Disorder
B. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a
substance or to another medical condition.
D. The occurrence of the major depressive episode is not better explained
by schizoaffective disorder, schizophrenia, schizophreniform disorder,
delusional disorder, or other specified and unspecified schizophrenia
spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode. Note:
This exclusion does not apply if all of the manic-like or hypomanic-like
episodes are substance-induced or are attributable to the physiological
effects of another medical condition.
 Management
• Pharmacotherapy
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
Tricyclic Antidepressants (TCADS)
Monoamine oxidase inhibitors (MAO-Is)
Others
Fluoxetine (PROZAC), 20-80 mg/d
Citalopram (CELEXA), 20-40 mg/d
Escitalopram (LEXAPRO), 10-20 mg/d
Sertraline (ZOLOFT), 50-200 mg/d
Paroxetine (PAXIL), 20-50 mg/d
Venlafaxine XR (EFFEXOR XR) 37.5- 225 mg/d -
Desvenlafaxine (PRISTIQ)
Duloxetine (CYMBALTA), 30-120 mg/d
Not commonly used due to side effects
Amitriptyline
Imipramine
Typically, non-selective & irreversible
MAO-A (NE, EPI, 5HT, DA)
MAO-B (trace amines, DA)
Selegiline (EMSAM)
Bupropion SR, XL (WELLBUTRIN) - 100-200 mg BID (SR) - 150-
450 mg/d (XL) Mirtazapine (REMERON), 15-45 mg/d
Trazodone, 50-200mg/noc (for sleep) Nefazodone
Management
• Psychosocial Therapy
1. Cognitive Therapy
2. Interpersonal Therapy
3. Behavior Therapy
4. Psychoanalytically Oriented Therapy
5. Family Therapy
Management
• Interventional Therapy
1. Electroconvulsive therapy (ECT)
2. Vagal Nerve Stimulation
3. Transcranial Magnetic Stimulation