Dr.

Imon Paul
MD, DPM
Asst. Prof, Dept of Psychiatry
IQ City Medical College
‘That’s the thing about depression: a human being can
survive almost anything, as long as he sees the end in
sight. But depression is so insidious and it compounds
daily, that it’s impossible to ever see the end.
The fog is like a cage without a key.’
Elizabeth Wurtzel, Prozac Nation
 More than 300 million people globally with
depression
 Increased Morbidity and Mortality
 Can affect individuals at any stage of the life
span, incidence highest in the middle ages
 Among the leading causes for ill health &
disability (WHO)
 Increased risk for suicide
 Commonest psychiatric disorder in primary
care
 Prevalence – Lifetime (5.25%), more in women
 Among those with any mental morbidity, 25%
were suffering from depression
 More than 80% had not received any treatment.
 Every 2 of 3 individuals with depression
reported disability in work life (67.3%), family
life (70.2%) and social life (68.6%).
 Often stigmatized and are excluded by family
and society
 Associated with poverty in a vicious cycle
 Sadness - emotion
experienced
universally

 Sadness – not
equal to
“depression”
 Diagnosis is clinical , “Syndrome”
Major criteria
 Depressed Mood

 Easy fatigability

 Loss of interest and

pleasure
(a) reduced concentration and attention
(b) reduced self-esteem and self-confidence
(c) ideas of guilt and unworthiness
(d) bleak and pessimistic views of the future
(e) ideas or acts of self-harm or suicide
(f) disturbed sleep
(g) diminished appetite
 Early morning worsening of sadness
 Terminal insomnia, Loss of libido
 Marked Psychomotor retardation or agitation
 Marked loss of appetite and weight
 Lack of mood reactivity
 Mood congruent / In congruent
 Delusions
Delusion of guilt, hypochondriasis, poverty,
nihilism, persecution
 Hallucinations
 Catatonic symptoms
 Mild Depression
 Moderate depression
 Severe Depression

Specifiers
 Somatic Symptoms

 Psychotic symptoms
 Mild – 2 major and 2 minor criteria
 Moderate – 2 major and 4 minor criteria
 Severe – 3 major and 4 minor criteria
 Somatic syndrome – 4 or more somatic
symptoms
 Melancholia
 Atypical depression
 Psychotic Depression
 Depression with seasonal pattern
 Dysthymia
 Bipolar depression
 Organic depression
 Substance induced depression
•Depression preceded by triggering life events -
Reactive depression
•Predominant physical symptoms - Somatisation
syndrome
•Multiple symptoms of depression in the apparent
absence of low mood - Masked Depression
•Without any triggering cause - Endogenous
Depression
 Importance of functional impairment
 Duration - more than 2 weeks
 Chronic depression – more than 2 years
 Dysthymia - Subsyndromal depressive
symptoms for more than 2 years
 Double Depression – dysthymia and major
depression
 Vague or unexplained physical symptoms like
gastro-intestinal problem or aches and pains
 Younger children - behavioral problems such
as social withdrawal, aggressive behavior or
apathy, sleep disruption, and weight loss
 Adolescents - somatic complaints, self-esteem
problems, rebelliousness, poor performance in
school, or a pattern of engaging in risky or
aggressive behavior

[Clinical Guidelines for treatment of depressive disorders, CJP,

2001]
Fariza Tanvir, 14,
Bangladesh –We
experience a lot of fear,
anxiety, defeat, pessimism,
insecurity, isolation,
inadequacy. Stand by us,
dear parents. We need
you.”
 Often unrecognized so goes untreated
 Thought to be normal aging process
 Somatic complaints are given precedence over
mood symptoms by patients
 Comorbid medical or neurological condition
often present
 Difficult to diagnose in the presence of
cognitive impairment
 Family history less commonly found
 More neuropsychological impairment
 Stronger relationship with subsequent
development of dementia
 More neurosensory hearing impairment
 More MRI T2 hyperintensity in deep white matter
 More common in vascular diseases like stroke,
DM,HTN
 Vascular factors may interact with psychosocial
factors to precipitate late life depression
 Overlap between medical and depressive
symptoms (fatigue, anorexia, insomnia, and
weight loss),
 Careful attention - cognitive and affective
symptoms of depression (including pervasive
anhedonia, hopelessness, crying, guilt, feelings of
worthlessness, and suicidal ideation)
 Both a cause and consequence of several
NCDs such as Ca, IHD , DM, substance use
disorders and nutritional disorders
 Hemodialysis - 6.5%  HIV - 30 %
 CAD - 20%  Hypothyroidism – 56 %
 Cancer - 25%  Diabetes - 20 %
 Stroke - 27%  Cushing’s - 50 %
 Parkinson’s - 30 %
 Multiple sclerosis- 30-40
%
 Epilepsy - 55%
 Dementia - 11%
 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 complaint

N = 1146 Primary care patients with major depression

Reference: Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.

 Bipolar Depression- Exclude Mania and
hypomania
 Anxiety disorders
 Substance related mood disorders
 Organic mood disorders
  Due to Emotional weakness (71 %)
 Caused by bad parenting (65 %)
 Victim’s fault; can will it away (45 %)
 Incurable (43 %)
 Consequences of sinful behaviour (35 %)
 Has a biological basis; involves brain (10 %)

[Lader MH & Cowen PJ, British Medical Bulletin, 2001; Ozmen et al,
2005]
Kiran Kumari, 18, India
-“It’s not your fault.
Depression can
happen to anyone. It is
just like any other
illness. Seek help. You
will rise again.”
 Early trauma and deprivation
 Attachment theory
 Beck’s – depressive triad
Social factors
 Negative life events
 Social support
 Genetics
 Alteration in Neurotransmitters
 Alteration of hormonal
regulations
 Alteration in sleep physiology
 Alteration in circadian rhythms
 Cerebral metabolic alterations
 Early onset depression – more heritable

Family studies-
 2-3 times higher risk of depression in
FDR of probands with depression

Twin Studies -
 Higher concordance rate in
MZ twins than DZ twins
 Most consistently implicated –
serotonergic & noradrenergic
circuits
 Limbic System
Prefrontal
Cortex

Locus Ceruleus (NE

Raphe Nuclei Source)
(5-HT source)

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

 Functional domains of Serotonin and Norepinephrine1-4

Serotonin (5-HT) Depressed Mood

Norepinephrine (NE)

Anxiety
Sex Concentration
Vague Aches and
Appetite pain Interest
Irritability
Aggression Motivation
Thought process

 Both serotonin and norepinephrine mediate a broad spectrum of

depressive symptoms
References:
2. Blier P, et al. J Psychiatry Neurosci. 2001;26(1):37-43.
1. Adapted from: Stahl SM. In: Essential Psychopharmacology: Neuroscientific
Basis and Practical Applications: 2nd ed. Cambridge University Press 2000. 3. Doraiswamy PM. J Clin Psychiatry. 2001;62(suppl 12):30-35.
4. Verma S, et al. Int Rev Psychiatry. 2000;12:103-114.
 It’s not all in your head

 Dysregulation of 5HT
and NE in spinal cord-
increased pain Descending Pathway

perception Descending
Pathway Ascending
Pathway

 Imbalances of 5HT and

NE -both emotional
Ascending
and physical Pathway

symptoms
Cortical-HPA axis
 Increased cortisol in depressed subjects

 Hypercortisolism – one of the most common

correlates of melancholic depression

Thyroid axis
 Sub-clinical hypothyroidism
 Decreased slow wave sleep
 Early onset of first episode of REM
sleep
 Decreased sleep maintenance
 Increase in intensity of REM sleep
 Sleep changes correlate with severity of
depression and normalize with
remission

Alteration of Circadian Rhythms

 Blunting of circadian rhythms
PET studies
 Decreased anterior
brain metabolism
 Increase in glucose
metabolism in Subgenual
prefrontal
several limbic cortex

regions

[Thase ME, 2001; Grasby P, 2002]

Assessment
 Severity

 Suicidal risk

 Psychotic symptoms

 Catatonic symptoms

 Substance abuse / other comorbidity

 Number of episode

 Past treatment-
drugs/dose/duration/response
Meghna Bhuyan, 14, India -
“Let your family and friends (‘colours’ of
your life) make you feel strong. Stay
connected with them. Depression won’t
last long.”
Screening Questionnaires
• “How have you been feeling recently?”
• “Have you been low in spirits?”
• “Have you been able to enjoy the things you usually enjoy?
• “Have you had your usual level of energy, or have you been feeling
tired?”
• “How has your sleep been?”
• “Have you been able to concentrate on your favourite tv shows?”

Self-report screening instruments

• Beck Depression Inventory (BDI)
• General Health Questionnaire (GHQ)

Can’t replace systematic clinical assessment – LISTENING

Hamilton Depression Rating Scale
(HAM-D)

Sum the scores from the first 17

items.
0-7 = Normal
8-13 = Mild Depression
14-18 = Moderate Depression
19-22 = Severe Depression
≥ 23 = Very Severe Depression
 Hamilton Depression Rating Scale (HAM-D): 21 Items

HAM-D17
Scores Depression
(Major Depressive Disorder)
15
Response
  50% reduction from baseline HAM-D score

7
Remission: HAM-D Score  7

References:
1. Frank E. Conceptualization and rationale for consensus definition terms in MDD, Arch Gen Psych. 1991; 48:851-855.
 High Suicidal risk
 Comorbid Substance abuse or serious medical
illness
 Catatonia
 Treatment resistance
 Severe depression
 Psychotherapies
 Antidepressants
 ECT
 Interpersonal therapy -works to change how
people accept self and relate to others that affects
mood and self-worth.
 CBT- helps change negative thinking, behavior
patterns and attitudes
Paulina Popy Kirana, 25,
Indonesia-“Depression speaks
as if our thoughts are definite
facts and the world seems
unfair. At this point it is
important to put down the
depression glasses by
recognizing the pattern of our
thoughts, and reaching out for
help.”
  Treatment aims at
 complete symptom remission,
 complete restoration of day-to day function
 prevention of relapses and recurrences.

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 All antidepressants equally effective
 Choice based on side effect profile and cost
 Adequate trial 6-8 weeks in adequate dose
 Change antidepressant if there is complete non
response after 4-6 weeks
 60% will respond to any adequate trial
 Combination of Antidepressants and
antipsychotics for psychotic depression
 Benzodiazepines as adjuvant in the initial
phase of treatment
 Educate family about need for supervised
medication
 Tricyclics
 SSRI
 SNRI- Venlafaxine, Duloxetine
 NaSSA- Mirtazepine
 NDRI- Bupropion
Suicide
Suicide
Final clinical pathway

6.5 lakh people committed suicide in India (2010-2014)

Males – most common in older

Female – most common in middle age

Recognizing depression at an early stage is critical

for reducing suicidal deaths and deliberate self-
harm
Almost 50% fail on first attempt

Previous attempters 23 times more likely to dies from suicide than

those without previous attempts

Internal stress
Pre-existing psychiatric morbidity
Demographics
Opportunities
  After one episode - 50% risk of a second
episode
 After two episodes - 70% risk of a third
episode
 After three episodes - 90% risk of a further
episode

[Practice Guidelines for treatment of

depression, American Psychiatric
Association, 2000]
Take Action!
Anupriya Nandy, 15, India -“If I
know someone who is depressed,
I give them love, affection and
care. I create happiness in their life
and help them in the best way I
can.”
 Be empathic and understanding
 Don’t try to “cheer up” a depressed
person—it can feel minimizing. Simply ask
if there is anything you can do to help—the
answer will often be “no,” but the support
will be felt.
 Avoid critical or shaming statements
 Challenge expressions of hopelessness
 Advocate for their recovery—
convey hope
 Emphasize that depression is very treatable
 Seek consultation
Didula Chenneth
Weerarathne, 15, Sri Lanka
-“Take small steps every
day. Make efforts to
maintain your daily routine
such as play outdoors,
spend time with family, do
your homework, and if you
continue to feel depressed,
seek professional help.”
 Reduce or eliminate the use of alcohol or drugs
 Exercise or engage in some form of physical
activity
 Eat a proper, well-balanced diet

 Establish a regular sleep

pattern
 Obtain adequate sleep
 Seek emotional support
 Focus on meaningful, positive aspects of life
 Modify schedule, set small, realistic goals

Depression is a temporary difficulty, not a

reflection of your whole life or self worth.
Diksha Kaul, 21, India
“When you look deeply into the eyes of a
person who is depressed, you see how they
long to break free from the ‘cage’ that their
mind has become. What’s the solution?
TALK: Talk to someone you trust, stay Active
and eat healthy, Learn something new, Keep
company of family and friends.”
 Episode: period lasting longer than 2 weeks, within full
symptomatic range on sufficient no. of symptoms to
meet syndromal criteria
• Partial remission: period during which sufficient
magnitude of improvement is noted /no longer fully
symptomatic, but continues to have more than minimal
symptoms.
 Response: A point where partial remission begins.
 Full remission: Brief (>2 weeks but <6 months)
period during which improvement of sufficient
magnitude is seen that the individual is asymptomatic.
 Recovery: A remission that lasts for 6 months or
longer.
 Relapse: Return of symptoms satisfying full
syndromal criteria for episode occurring during
remission, but before recovery.

 Recurrence: Appearance of a new episode of

MDD, can only occur during a recovery.