depressive disorders.pptx psychiatry disorder

Depressive disorder

1. Depressive disorders Dr. Martha Gobena :MD, Assistant professor of psychiatry July 11,2024

2. Outlines Introduction Epidemiology Clinical presentations Etiology Diagnosis and Classification of depressive disorders Treatment

3. Introduction Mood refers to a sustained emotion that colours the way we view life. Disorders of mood are often called affective disorders, since affect is the external display of mood. Depression and mania are often seen as opposite ends of an affective or mood spectrum. Disorder that looks more like the expression of a continuum than a useful category.

4. Introduction cont , Depression has a range of meaning from a description of normal unhappiness through persistent and pervasive ways of feeling and thinking to psychosis. is a complex diagnostic construct in which the essential ingredients are a depressed mood and a loss of interest

5. Epidmiology The lifetime rates of major depressive disorder in childhood range from about 0.6 to 4.8 percent . prevalence of major depressive disorder increased significantly across adolescence, with markedly greater increases among females than among males.

6. Correlates of mood disorders Gender approximately two fold more common among women than men. This gender difference begins in early adulthood, is most pronounced in people between the ages of 30 and 45, and also persists in the elderly.

7. Aside from biological–hormonal differences) that show that female gender per se means increased vulnerability for depression increased stress sensitivity, maladaptive coping strategies and multiple social roles. substance use disorders that can mask depressive symptoms (more frequently seen in men) have been suggested

8. Age Depressive disorders show much higher lifetime prevalence among people younger than 45 years. Social stressors appear to place younger individuals at a greater risk for depression than elderly ones. On the other hand, isolation, loss of interpersonal contacts, medical disorders, and disability play a more important role in the development of depression in later life.

9. Marital status Major depressive disorder and bipolar illness are most frequent among divorced, separated, or widowed individuals. Single women have lower rates of depression than married women do, but the opposite is true for men.

10. Socio economic Individuals with lower socioeconomic status have a lower level of educational, lower income poorer living conditions higher rate of unemployment homelessness.

11. Residence major depression was more frequent in urban residents than in their rural counterparts. As urban communities are more stressful than rural ones.

12. Social stressors chronic stressors ( e.g.unemployment , difficult marriage) play a more important Accumulation of stressful negative life events is the strongest predisposing factor. Social support Poor social support is related to onset, relapse, and recurrence of depression,

13. Clinical presentation A depressed mood and a loss of interest or pleasure are the key symptoms of depression. Depressed mood Patients may say that they feel blue, hopeless, in the dumps, or worthless, Emptiness ,Unhappiness and Distress For a patient, the depressed mood often has a distinct quality that differentiates it from the normal emotion of sadness or grief.

14. Clinical featurs con.. Anhedonia — Loss of Interest They are unable to draw pleasure from previously enjoyable activities. In severe cases they disregard and abandon most of the things they valued in life.

15. Vegetative states They are manifested as profound disturbances in eating in sleep in sexual function loss of vitality motivation, energy and capacity to respond positively to pleasant events. diffuse pains, and complaints of fatigue and physical discomfort are reported.

16. Mental State examination. The classic presentation of a depressed patient is a person with a stooped posture, decreased movement downward averted gaze. Peculiar triangle-shaped fold in the nasal corner of the upper eyelid- Veraguth’s fold

17. Psychomotor disturbance Agitation usually accompanied by anxiety, irritability, restlessness, hand wringing and hair pulling. Retardation slowing of bodily movements mask-like facial expression lengthening of reaction time to stimuli, increased speech paucity as an inability to move or to be mentally and emotionally activated (stupor),

18. Speech Many depressed patients have a decreased rate and volume of speech; They respond to questions with single words and exhibit delayed responses to questions. Mood, Affect, and Feelings Depression is the key symptom in which 50% deny feeling & don’t appear to be particularly depressed.

19. Thought Their thought content often includes non delusional ruminations about loss, guilt, suicide, and death. About 10% of all depressed patients have marked symptoms of a thought disorder, usually thought blocking and profound poverty of content. Perception Depressed patients may complain of either hallucinations.

20. Judgment, Insight and Reliability Depressed patients hyperbolic; they overemphasize their symptoms, their disorder & their life problems. It is difficult to convince such pts. that improvement is possible. overemphasize the bad and minimize the good. ( it is not fabrication)

21. Cognitive disturbance Difficulty in concentrating negative thoughts low self-esteem and self confidence, hopelessness sense of worthlessness and sinfulness, negative outlook on the world suicidal thoughts. Memory – have memory loss and disturbance.

22. MSE cont ………. Impulse Control About 10-15 % of all depressed patients commit suicide, and about two-thirds have suicidal ideation. Depressed pts. with psychotic features can be homicidal as a result of their delusional systems, but the most severely depressed pts. often lack the motivation/energy to act in an impulsive/violent way. At increased risk of suicide as they begin to improve/regain the energy needed to plan/carry out a suicide-paradoxical suicide.

23. Etiology Genetic Neurobiological factors ; Neurotransmitters (dopamine, serotonin, NE,Ach ) Neuroendocrine abnormalities (thyroid H, HPA axis) structural & functional brain abnormalities Psychosocial factors ; Social support Cognitive theory ; negative view about self the world and the future life events & interpersonal difficulties 23

24. DIAGNOSIS Depressive disorders can take many forms, depending on their severity and chronicity. The disorder that we most associate with “classic” depression is major depressive disorder. It is essential to understand the different varieties of depressive disorders

25. Classification Depressive disorder include 1 Major depressive disorder (including major depressive episode) 2 Persistent depressive disorder (dysthymia) 3 Disruptive mood dysregulation disorder 4 Premenstrual dysphoric disorder 5 Substance/medication-induced depressive disorder 6 Depressive disorder due to another medical condition 7 Other specified depressive disorder 8 Unspecified depressive disorder 25

26. DSM-5 Diagnostic Criteria for Major Depressive Disorder Major Depressive Disorder Duration 2 wk Symptoms Dysphoria or feeling depressed Anhedonia /loss of interest ↑ or ↓ weight or appetite ↑ or ↓ sleep ↑ or ↓ activity ↓ energy Depressing thoughts: worthlessness, guilt ↓ concentration Suicidal ideation/plan

27. Required number of symptoms 5 (1 has to be one of the first two listed) Psychosocial consequences of symptoms Distress or impaired functioning (social, occupational, or other significant areas) Exclusions (Not better explained by):Medical illness ,Substance or Other psychiatric disorder like History of mania or hypomania

28. With anxious distress. A patient has symptoms of anxiety, tension, restlessness, worry, or fear that accompanies a mood episode. With catatonic features. There are features of either motor hyperactivity or inactivity. Catatonic features can apply to major depressive episodes and to manic episodes

29. With peripartum onset. A manic, hypomanic, or major depressive episode (or a brief psychotic disorder) can occur in a woman during pregnancy or within a month of having a baby With psychotic features. Manic and major depressive episodes can be accompanied by delusions, which can be mood-congruent or -incongruent

30. Specifiers Describing Course of Recurring Episodes These specifiers describe the overall course of a mood disorder, not just the form of an individual episode. With rapid cycling. Within 1 year, the patient has had at least four episodes (in any combination) fulfilling criteria for major depressive, manic, or hypomanic episodes. With seasonal pattern . These patients regularly become ill at a certain time of the year, such as fall or winter

31. Specifiers for Depressive Disorders cont …. Specify current severity : Severity is based on the number of criterion symptoms, the severity of those symptoms, and the degree of functional disability. Mild : Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable , and the symptoms result in minor impairment in social or occupational functioning. 31

32. Specifiers for Depressive Disorders cont …. Moderate : The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.” Severe : The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning . 32

33. Dysthymic Disorder (persistent depressive disorder) Dysthymic disorder (also called dysthymia) is the presence of depressive symptoms that are less severe than those of major depressive disorder. Although less severe than a major depressive disorder, it is often more chronic

34. dysthymia also known as persistent depressive disorder, is the presence of a depressed mood that lasts most of the day and is present almost continuously. There are associated feelings of inadequacy, guilt, irritability, and anger; withdrawal from society; loss of interest; and inactivity and lack of productivity.

35. DSM-5 Diagnostic Criteria for Persistent Depressive Disorder Duration 2+ yr (1+ yr for children) ≤2-mo symptom free during illness Symptoms Depressed mood most of the time ↓ appetite ↓ or ↑ sleep ↓ energy ↓ self-esteem ↓ concentration/decision making ability Hopelessness Required number of symptoms First symptom and 2+ of rest Psychosocial consequences of symptoms Distress and functional impairment.

36. Double Depression . Persistent depressive disorder with major depressive episode 40 percent of patients with major depressive disorder also meet the criteria for dysthymia, a combination often referred to as double depression. Have a poorer prognosis than patients with only major depressive disorder 36

37. Postpartum blues Begins 2-4 day postpartum, peaks within 10 days and subsides usually within 3 weeks after delivery. Transient period of mild depression, mood instability, anxiety, decreased concentration; Usually mild or absent: feelings of inadequacy, anhedonia, increases the risk for a postpartum major depressive episode 37

38. MAJOR DEPRESSIVE DISORDER WITH PERIPARTUM ONSET (POSTPARTUM DEPRESSION) MDD that occurs during pregnancy or in the 4 wk following delivery. Typically lasts 2-6 month; residual symptoms can last up to 1 yr . • Usually associated with mania , but also with MDE. • Severe symptoms include extreme disinterest in baby, suicidal and infanticidal ideation 38

39. postpartum depression cont …… The risk of postpartum episodes with psychotic features is particularly increased for women with ; 1 prior postpartum mood episodes 2 prior history of a depressive or bipolar disorder (especially bipolar I do) 3 those with a family history of bipolar disorders. 39

40. postpartum depression cont …… psychosocial factors: stressful life events, :unemployment, :marital conflict, :lack of social support, :unwanted pregnancy, :colicky or sick infant 40

41. Prognosis impact on child development: increased risk of cognitive delay, insecure attachment, behavioral disorders . • Treatment of mother improves outcome for child at 8 month through increased mother-child interaction.

42. Premenstrual dysphoric disorder Higher prevalence of depressive disorders in women due to premenstrual affective changes Prevalence1.8% and 5.8% A few days before her menses, a woman experiences symptoms of depression and anxiety dysphoria, tension, irritability, hostility, and labile mood accompanied by behavioral and physical symptoms. 42

43. Premenstrual dysphoric disorder Women with severe premenstrual complaints appear to have higher rates of lifetime major mood disorders Many individuals, as they approach menopause, report that symptoms worsen. Symptoms cease after menopause Heritability range between 30% and 80%, with the most stable component of premenstrual symptoms estimated to be about 50% heritable. 43

44. Depressive disorder due to another medical condition A variety of medical and neurological conditions can produce depressive symptoms; these need not meet criteria for any of the conditions above . Mood disturbance in this case is etiologically related to the general medical condition through a physiological mechanism 44

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46. Substance/medication- induced depressive disorder Alcohol or other substances (intoxication or withdrawal) can cause depressive symptoms; these need not meet criteria for any of the conditions above . The depressive symptoms persist beyond the expected length of physiological effects, intoxication, or withdrawal period. Intense depressive symptoms can last for a long period after the cessation of substance use. 46

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48. Good prognostic factor for MDD Mild episodes The absence of psychotic symptoms Short hospital stay and no more than one previous hospitalization for major depressive disorder Solid friendships during adolescence, Stable family functioning, and generally sound social functioning for the 5 years preceding the illness Absence of a comorbid psychiatric disorder and of a personality disorder An advanced age of onset

49. Poor prognostic factor for MDD coexisting dysthymic disorder abuse of alcohol and other substances anxiety disorder symptoms history of more than one previous depressive episode. Men are more likely than women to experience a chronically impaired course.

50. Suicide and deliberate self harm There are about 5000 suicides each year in England and Wales, of which 400-500 involve overdoses of antidepressants. Deliberate self harm is 20-30 times commoner. Not all people who commit suicide have psychiatric illness, but, among those who do, depression is the commonest illness and 15% of depressed patients eventually kill themselves.

51. Assessment of risk is thus important and guides treatment. Many older antidepressants are often fatal in overdose While the newer effective drugs—such as selective serotonin reuptake inhibitors are safer and should be used with high risk patients.

52. Suicide or deliberate self harm Features to be assessed Motive Circumstances of attempt Psychiatric disorder Precipitating and maintaining problems Coping skills and support Risk

53. High risk indicators for suicide Male Age > 40 years Family history of suicide Unemployed Socially isolated Suicide note Continued desire to die Hopelessness, sees no future Misuse of drugs or alcohol Psychiatric illness (especially depression, but also schizophrenia, personality disorder)

54. TREATMENT APPROACH Goals of Treatment First t he patient's safety must be guaranteed second complete diagnostic evaluation of the patient is necessary Third initiate a treatment plan that addresses not only the immediate symptoms but also the patient's prospective wellbeing

55. CHOICE OF TREATMENT SETTINGS Hospitalization Definite indications for hospitalization the risk of suicide or homicide a patient's grossly reduced ability to get food and shelter the need for diagnostic procedures rapidly progressing symptoms the rupture of a patient's usual support systems

56. Outpatient Dysthymia and some forms of milder depression can be treated in the office if there is Minimal Clinical signs of impaired judgment, weight loss, or insomnia Reliable patient’s support system

57. TREATMENT OPTIONS Common Antidepressants Electroconvulsive therapy (ECT) Psychosocial interventions Other less commonly used Repetitive transcranial magnetic stimulation (rTMS) Light therapy Transcranial direct stimulation Vagal nerve stimulation Deep brain stimulation Sleep deprivation

58. Choosing Treatment Option Combined Treatments May Offer the Best Option pharmacotherapy + psychotherapy = higher response and higher remission rate Selection of an initial treatment modality should be influenced by clinical features (e.g., severity of symptoms, presence of co-occurring disorders or psychosocial stressors) as well as other factors (e.g., patient preference, prior treatment experiences)

59. PHASES OF TREATMENT Acute phase Continuation phase Maintenance phase

60. Acute Phase Treatment Treatment in the acute phase should be aimed at inducing remission of the major depressive episode and achieving a full return to the patient’s baseline level of functioning Pharmacotherapy objective of pharmacologic treatment is symptom remission, not just symptom reduction

61. Antidepressant Antidepressants are recommended for the treatment of moderate to severe depression and for dysthymia All patients should be informed about the withdrawal (discontinuation) effects of antidepressant antidepressants may take up to 3 to 4 weeks to exert significant therapeutic effects, although they may begin to show their effects earlier TCA, SSRI, MOAI

62. Classes of antidepressants First generation TCAs Amitriptyline Nortriptyline Imipramine Clomipramine Desipramine Trimipramine Second generation TCAs Doxepine Dothiepine

63. TCA side effects Sedation, dry mouth, constipation Worsening cognitive problems in elderly

64. SSRI Citalopram Fluvoxamine Paroxetine Sertraline Fluoxetine MAOIs Moclobemide Phenelzine Tranylcypromine

65. Dose and side effect SSRI Its better tolerated but the common side effects are Sexual dysfunction stomach upset Drowsiness hyperprolactinemia Weight gain SIADH Insomnia hyponatremia Anxiety serotonin syndrome Head ache Dry mouth Blurred vision Nausea Rash

66. Serotonin syndrome It is life threatening condition associated with increased serotonergic activity in CNS It is seen with therapeutic medication use or intentional self poisoning Classically described as triads are -mental status change -autonomic hyperactivity -neuromuscular abnormalities

67. Diagnosis is made solely on clinical grounds and the clinical features are Mental state changes Autonomic Neuromuscular Anxiety Diaphoresis Tremor Agitated delirium Tachycardia Muscular rigidity Restlessness Hyperthermia Myoclonus Disorientation HTN Hyperreflexia Vomiting Diarrhea

68. Management principles Discontinuation of all serotonergic agents Supportive care to normalize v/s Sedation with benzodiazepines Administration of serotonin antagonist Assessment of the need to resume use of causative serotonergic agent after the resolution of the symptoms

69. Dose and duration The use of too low a dosage for too short a time an unsuccessful trial of an antidepressant drug Unless adverse events prevent it, the dosage of an antidepressant should be raised to the maximum recommended level and maintained at that level for at least 4 or 5 weeks before a drug trial is considered unsuccessful

70. Electroconvulsive therapy ECT is particularly effective in treating depression with psychotic features Patients who do not respond to antidepressant drugs may respond to ECT It is essential to continue drug treatment with antidepressants after a successful course of ECT There is no absolute contraindications to its use There is no evidence that it causes brain damage or permanent intellectual impairment

71. Psychosocial Therapy Usually recommended for patients with depression who are experiencing stressful life events, interpersonal conflicts, family conflicts, poor social support and comorbid personality issues S hort-term psychotherapies Cognitive- Behavioral therapy Interpersonal therapy Psychoanalytically Oriented Therapy Family therapy

72. 1.Cognitive-behavioral Therapy Developed by Aaron Beck F ocuses on the cognitive distortions postulated to be present in major depressive disorder The goal of cognitive therapy is to alleviate depressive episodes and prevent their recurrence by helping patients identify and test negative cognitions develop alternative, flexible, and positive ways of thinking rehearse new cognitive and behavioral responses

73. Behavior Therapy is b ased on the hypothesis that maladaptive behavioral patterns result in a person's receiving little positive feedback and outright rejection from society P atients learn to function in the world in such a way that they receive positive reinforcement

74. Interpersonal Therapy D eveloped by Gerald Klerman Focuses on one or two of a patient's current interpersonal problems Has two assumptions Current interpersonal problems are likely to have their roots in early dysfunctional relationships Current interpersonal problems are likely to be involved in precipitating or perpetuating the current depressive symptoms

75. TREATMENT IN CONTINUATION PHASE Maintain the gains achieved in the acute phase of treatment and prevent relapse of symptoms Continue the same dose of antidepressant for 16-24 weeks to prevent relapse

76. DISCONTINUATION OF TREATMENT to discontinue or terminate psychotherapy in the maintenance phase, the manner in which this is done may be individualized to the patient's needs to discontinue maintenance pharmacotherapy, it is best to taper the medication over the course of at least several weeks to few months

77. Pregnancy and post partum Tricyclics cross the placenta and neonatal drug withdrawal syndrome includes tachypnea, cyanosis, irritability, and poor sucking reflex. If possible, tricyclic and tetracyclic medications should be discontinued 1 week before delivery. Large Finnish study found SSRI use to be associated with a lower risk of pre‐term birth and caesarean delivery compared with unexposed women diagnosed with a psychiatric illness Untreated maternal depression itself is associated with an increased risk of both low birth weight and pre‐term birth SSRIs do not appear to increase the risk of stillbirth or neonatal mortality

78. Sertraline appears to result in the least placental exposure SSRIs appear not to be major teratogens with most data supporting the safety of fluoxetine Women who take antidepressants during pregnancy may be at increased risk of - developing hypertension - pre‐eclampsia -post‐partum hemorrhage

79. Breast feeding It is usually advisable to continue the antidepressant prescribed during pregnancy Switching drugs post partum for the purpose of breastfeeding is usually not sensible In each case previous response to treatment must be considered When initiating antidepressant post partum sertraline or mirtazapine can be considered

80. 1. Kaplan & sadock’s comprehensive textbook of psychiatry 10 th edition 2. kaplan and sadok’s synopsis of psychiatry , 12th edition 3. DSM-5 th edition 4. Mario_ Maj ,_ Norman_Sartorius_Depressive_DisordersBook

81. Thank you