SOLWEZI GENERAL HOSPITAL

MENTAL HEALTH TEAM

MAJOR
DEPRESSION
OUTLINE
• Definition of terms
• Etiology
• Clinical presentations
• Diagnostic criteria
• Differential diagnosis
• Management
DEFINITIONS OF TERMS
• MOOD: a mood is an internal subjective emotional feeling of an
individual. The mood influences someone's behavior in several ways.
• Even if mood is subjective, an intelligent individual can tell another
persons mood. In this case the mood is said to be affect.
• AFFECT: the term affect means the emotional state as revealed
through facial expressions and gestures.
• MOOD DISORDERS: a mood disorder is a pervasive and sustained
feeling that is experienced internally and that influences a persons
behavior and perception of the world.
Cont…
• The mood state of a normal individual fluctuates between
mild depression to mild elation depending on many factors.
• For example: if someone passes an examination she or he
may be elated or happy; if she fails she or he may be a little
depressed or sad.
•  Only when the mood swing is excessive in severity and In
duration and when it interferes with a person’s day-to-day
activities that it becomes a mood disorder.
Cont…
• Mood disorders are mental health disorders that involve emotional
disturbances consisting of long periods of excessive
sadness(depression), excessive joyousness or elation(mania), or both.
• NB: Depression and Mania represent the two extremes or poles of
mood disorders.

Mania Depression
Classifications
• Depression
• Mania
• Bipolar mood disorder
DEPRESSION
• Is a mood disorder characterized by feeling of worthlessness,
hopelessness, helplessness, suicidal ideation and loss of interest in all
pleasurable activities.
• Depression may be a normal mood state if it follows a painful,
distressing situation and if it is short-lived.
• All of us at times feel depressed for a variety of reasons and after
some time we come out of that gloom to normal state.
• This what we call reactive depression
Exogenous depression
• Depression may come about as reaction to an event, such as the
death of a loved one or a change in financial situation,
Psychotic or endogenous depression
A depressive episode can be classified as endogenous depression if;

• If depressive mood is very severe in intensity and if it is going to create

problems for the individual and others.
• If it is going to interfere with the individual day-to-day activities and if it is
prolonged, then this depression is abnormal.
• It occurs without any obvious external cause.
PREDISPOSING FACTORS
• Biological factors
• Genetic factor numerous studies have been conducted which support the
involvement of heredity in depressive disorders.
• Biochemical: Depression is due to the imbalance of biochemical (ie: serotonin
and norepinephrine) in the brain.
• Psychosocial factors
• Life events and Environmental Stress which include the following:
• Parental Deprivation
• Separation
• Loss of significant figure
• Lack of adequate care
Cont…
• Relationship with parent
• Physical/sexual abuse
• None caring/overprotective parenting style
• Low self-esteem
• Changes of roles
Four (4) Vulnerability Factors
1. Loss of mother before the age of 11.
2. 3 or more children at home under 14 years
3. Lack of confiding relationship.
4. Unemployment.
Psycho-analytical Theory
• Reaction to a loss of an attachment figure
• Loss of a parent in early life made the person vulnerable
later on to depression.
Personality type
• Introverts
• Unassertiveness
• Insecurity
• Dependency
Clinical features
• Profound sadness
• Must last at least 2 weeks
• With 4 or more of the following seven symptoms:
1. Feeling of worthlessness or guilt
2. Impaired concentration
3. Loss of energy and fatigue
4. Thoughts of suicide
5. Loss or increase of appetite and weight
6. Insomnia or excessive sleep and
7. Retardation or a agitation
Biological/Physical symptoms
1. Insomnia or hypersomnia(middle, early and initial insomnia).
2. Loss of appetite or increased appetite( usually with specific
cravings).
3. Loss of weight/weight gain
4. Lack of energy
Depressive ideation
• Pessimism:
1. Hopelessness
2. Helplessness
3. Worthlessness
Psychotic features (mood congruent)
1. Nihilistic delusions
2. Delusions of guilty
3. Delusions of poverty
Psychomotor activity
• Psychomotor agitation
• The patient finds it difficult to sit still.(restlessness)
• Psychomotor retardation
1. Slowed thinking
2. Slowed activity
3. Stupor in severe cases
Suicide
• Presence of marked hopelessness
• Written verbal communication of suicidal intent or plan.
• Early or recovery stages of depression.
Reactive and endogenous depression
• Differences between Reactive (Exogenous) and Endogenous Depression
Reactive Endogenous
• Response to a loss Even without a loss

• No Delusions always present delusion

• No Hallucinations present hallucinations

• Early insomnia Late insomnia

• Needs medication May recover without medication

DIAGONISTIC CRITERIA
• The patient should present with at least five or more of the above
stated symptoms and have been present during the same two weeks
period and represent a significant change from previously functioning.
• The symptoms should cause clinically significant distressand
impairment in social, occupational or any other important areas of
functioning.
• There should have been no manic or hypomanic episode unless it was
substance induced or as a result of other medical conditions.
DIFFERENTIAL DIAGNOSIS
• Manic episodes with irritable mood: major depressive episodes
characterized by prominent irritable mood may be difficult to
distinguish from manic episode with irritable mood or mixed episode.
• Mood disorders due to other medical conditions
• Substance induced depressive or bipolar disorder.
• Attention deficit hyperactivity disorder- distractibility and low
frustration tolerance can occur in both ADHD and major depressive
disorder.
MANAGEMENT
NON PSYCHO-PHARMACOLOGYCAL
MANAGEMENT.
• Suicide risk assessment:
• Ask client directly about suicidal ideas
• Ask questions such as:
1. ‘’have you thought about killing yourself?”
2. or “Have you thought about harming yourself in any way?
3. ‘’If so, what do you plan to do?’’
4. ‘’ Do you have the means to carry out this plan?’
5. ’where?
Psychotherapy

• psychotherapy means understanding the depressed patients and their

problems and guiding them positively.
• It includes reassurance and supportive measures, and encouraging patients to
freely communicate with the therapist.
• The emotional ventilation has dramatic effect in relieving depression.
• Family therapy,
• group therapy and
• Art therapy
• music therapy
• cognitive therapy are also indicated.
• The selection of treatment depends on the individual patients.
Cognitive therapy
• CBT will encourage the patient to examine real life experiences to see
what happens to her or to others with a similar situations.
• Then in the light of a more realistic perspective, she may be able to
take the chance of testing out what others think.
• CBT will also help correct misinterpretations.
Family therapy
• Is a psychotherapy that targets the family members who may be
experiencing problems conflicts as a result of the patients illness. The
goal is to improve these conflicts.
Health education
• Importance or drug compliance
• Side effects of drugs
• Importance of coming for review
• Signs and symptoms of relapse
• Importance of joining support groups in the community
• To avoid taking alcohol with the medication
• Storage of drugs at home
• Avoiding stigmatizing the patient
 PSYCHO-PHARMACOLOGICAL
MANAGEMENT
The psycho-pharmacological management of depression is based on the
monoamine theory.
According to this hypothesis, depression is a functional deficit of
monoamine transmitters; serotonin(5-
hydroxytriptamine),norepinephrine and dopamine.
• Psychopharmacology Major categories of antidepressants include
• Cyclic antidepressants,
• Monoamine oxidase inhibitors (MAOIs),
• Selective serotonin reuptake inhibitors (SSRIs),
• Atypical antidepressants.
SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS

MODE OF ACTION
As the name entails it inhibits the reuptake of 5-HTT from the synapstic cleft to the pre-
synaptic neuron.
ADVANTAGES
Easy of dosing, may be better tolerated than TCAs, less cardio toxicity, fever, anticholinergic
side effects, low toxicity in overdose.
DISADVANTAGES
Commonly cause GI upset, headache, restlessness and, insomnia, problems on discontinuation
Examples: fluoxetine- 20mg daily as single or devided dose with 60mg daily as maximum
Fluvoxamine:50-100mg noct which can b increased upto 300mg in devided doses if it
exceeds15mg
Paroxetine:20mg daily, as morning dose, can be increased upto 50mg.
MONAMINE OXIDASE INHIBITOR
• Inhibit the activity of one or both monoamine oxidase enzymes.
(MAO- A and MAO -B)
• MAOIs are used infrequently because of potential fatal side effects
and interactions with numerous drugs.
For example phenelzine- 15mg tds can be increased to Qid after two
weeks of no response with 30mg as maximum dose.
TRYCYCLICS
• MODE OF ACTION
They block the reuptake of monoamines into the cerebral and other nerves which increases
the concentration of amines of the synaptic cleft.
ADVANTAGES
Possibly more effective in severe depression and cost efficient
DISADVANTAGES
Toxicity in overdose, may be less tolerated than SSRIs, all TCAs may show cardiac conduction
and lower seizure threshold.
Example: imipramine 75mg daily. Can be increased up to 150-200mg and up to 150 can be
given nocte.
amitriptyline 50mg in divided doses and can be increased in steps of 25mg with 150mg as
max dose daily.
Electroconvulsive Therapy (ECT)
• ECT involves application of electrodes to the head of the client to
deliver an electrical impulse to the brain which this causes a seizure. It
is believed that the shock stimulates brain chemistry to correct the
chemical imbalance of depression.
• Psychiatrists may use electro- convulsive therapy (ECT) to treat
depression in selected groups, such as clients who do not respond to
antidepressants or those who experience intolerable side effects at
therapeutic doses.
Thank you…