DEPRESSIVE DISORDER

Chairman: Prof. Dr Naba Raj Koirala

Moderator: Dr Rajan Mishra, Lecturer
Presenter: Resident Dr Sirshak Deep Shrestha
Department of Psychiatry and Mental Health
Birat Medical College and Teaching Hospital
CONTENT
• OVERVIEW
• CLINICAL PRESENTATION
• DIAGNOSIS
• DIFFERNTIAL DIAGNOSIS
• CO-MORBIDITIES
• TREATMENT
OVERVIEW
• Depression is a common illness worldwide

• An estimated of 3.8% of the population are affected.

• Depression at its worst can lead to suicide.

• Over 700,000 people die due to suicide every year

WHO 2021
Depression is by definition, a mood disorder, and disturbances of mood
are at the core.
CLINICAL PRESENTATION
• Central features are:
• Depressed mood
• Loss of interest and enjoyment
• Reduced energy

• Reduced concentration and attention

• Reduced self-esteem and self confidence
• Ideas of guilt and unworthiness
• Bleak and pessimistic views of the future
• Ideas or acts of self harm or suicide
• Sleep disturbances
• Diminished appetite
NEUROVEGETATIVE SYMPTOMS OF
DEPRESSION
• Common:
• Fatigue, low energy
• Inattention
• Insomnia, early morning awakening
• Poor appetite, associated weight loss

• Sometime included:
• Decrease libido and sexual performance
• Menstrual irregularities
• Worse depression in AM
PRESENTATION IN SPECIAL
POPULATIONS
• Depression in children and adolescents:
• School phobia, excessive clinging to patients, poor academic performance,
substance abuse, antisocial behavior, sexual promiscuity, truancy may be
symptoms of depression in adolescents

• Depression in Older People:

• Depression is more common in older persons than it is in general population.
• Prevalence rate ranging from 25-50 %
• Depression in older person correlates with low socio economic status, the loss
of spouse, concurrent physical illness, and social isolation
• Disorder appears more often with somatic complaints
DIAGNOSIS
MAJOR DEPRESSIVE DISORDER (MDD)
• Primary feature of major depressive disorder is the occurrence of at least
one episode of major depression, which is significant depressive
symptoms that last for a significant time

• With Psychotic Features:

• Mood-Congruent: Psychotic symptoms in harmony with the mood disorder.
• Mood-incongruent: Psychotic symptoms not in harmony with the mood disorder
MAJOR DEPRESSIVE DISORDER
• With Melancholic Features:

• Depression characterized by severe anhedonia, early morning awakening, weight

loss, and profound feelings of guilt(often over Trivial events)

• Melancholia is associated with changes in autonomic nervous system and

endocrine functions, also referred as endogenous depression ( depression that
arises in the absence of external life stressors or precipitants.
ICD 10 AND DSM-5
• Both system contain categories for single episodes of mood disorder
as well as categories for recurrent episodes.
• Both recognizes milder but persistent depressive states (Dysthymia)
• Both classify depressive episodes on the basis of severity and whether
or not psychotic features are present
• Melancholic(DSM-5) , Somatic (ICD-10)
ICD 10 AND DSM-5
• In DSM-5 an episode of Major Depression with appropriate clinical
symptomatology can be specified as atypical depression whereas in
ICD10 atypical depression is classified separately under other
depressive episodes.

• In DSM-5 mood disorders that are judged to be secondary to a

medical condition are included in subcategory of mood disorders,
whereas in ICD-10 it is under Organic Mental Disorders.
MAJOR DEPRESSIVE DISORDER
• With atypical features

• Post partum onset

• Seasonal pattern
DYSTHYMIC DISORDER
• Also called Dysthymia is the presence of depressive symptoms that
are less severe than those of MDD
• Less severe but Chronic
• Most typical feature of 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.
• Distinguished from MDD, by the fact that patients complains that they
have always been depressed
• Early onset, beginning in childhood or adolescence, and almost always
by a patient’s 20s
OTHER DIAGNOSES
• Minor Depressive Disorder

• Recurrent (Brief) Depressive Disorder

• Double Depression
OBJECTIVE RATING SCALES FOR
DEPRESSION
• Clinician administered scales:
• Hamilton Rating Scale for Depression (HAM-D)
• Self-Administered scales:
• Zung Self Rating Scale: 20 items report scale. Normal 34 or less; depressed
score 40
• Raskin Depression Scale:
• 5 point scale of three dimensions: Verbal Report, Displayed Behavior, and secondary
symptoms.
• Scale ranges from 3-13; normal score is 3, and depressed score is 7 or more
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• General Medical Disorders:

• Test patients who are markedly overweight or underweight for adrenal and
thyroid dysfunctions

• Test patients with appropriate risk factors for HIV, and older patients for viral
pneumonia and other medical conditions
DIFFERENTIAL DIAGNOSIS
• Neurologic conditions:
• Most common neurologic that manifest depressive symptoms are Parkinson
disease, dementing illness, epilepsy, cerebrovascular diseases and tumors

• Parkinson disease:
• The motor symptoms of Parkinson disease can mask a depressive disorder as the motor
symptoms are similar.

• Cerebrovascular disease:
• Depression is a frequent complicating factor of cerebrovascular disease, particularly in
the 2 years after the episode
DIFFERENTIAL DIAGNOSIS
• Neurologic conditions:
• Depression is more common in anterior brain lesions than in posterior brain
lesions, in both cases often responds to antidepressant medications.

• Tumor of the diencephalic and temporal regions are particularly likely to be

associated with depressive disorder symptoms.
DIFFERENTIAL DIAGNOSIS
• Neurologic conditions:
• Dementia:
• Major depressive disorder can have profound effect on concentration and memory and can occasionally be
confused with neurodegenerative illness.

• The cognitive symptoms in Major depressive disorder have a sudden onset, and other symptoms of disorder.

• A diurnal variation of cognitive problem occurs in depression not in dementia.

• Depressed patient with cognitive difficulties often do not try to answer questions, patient with dementia may
confabulate.

• Depressed patient can be coached and encouraged into remembering.

DIFFERENTIAL DIAGNOSIS
• Features of a Depressive episode that are more predictive of Bipolar
Disorder:
• Early age of onset
• Psychotic depression before 25 years of age
• Rapid onset and offset of depressive episodes of short duration(>5 episodes)
• Depression with marked psychomotor retardation
• Atypical features
• Seasonality
• Bipolar Family History
• Hyperthymic temperament
• Repeated (at least 3 times) loss of efficacy of antidepressants after initial response
CO-MORBIDITIES
CO-MORBIDITIES
• Anxiety

• Substance use disorder.

• Medical conditions
COURSE
• Several studies has concluded that mood disorders have long courses
and that patients tent to have relapses
• Onset:
• The first depressive episode occurs before age 40 years in about 50% of
patients.
• Later onset is associated with the absence of a family history of mood
disorders, antisocial personality disorder and alcohol abuse.
COURSE
• Duration:
• An untreated depressive episodes lasts 6-13 months; most treated episodes
last about 3 months.
• The withdrawal of antidepressants before 3 months- relapse of symptoms
• As the course of the disorder progresses, patients tend to have more frequent
episodes that last longer
TREATMENT
• Goals:
• First, the patients safety must be guaranteed.

• Second, a complete diagnostic evaluation of the patient is necessary.

• Third, we should initiate a treatment plan that addresses not only the
immediate symptoms but also the patient’s prospective well-being.
TREATMENT
• Hospitalization:
• Definite indicator: risk of suicide or homicide, patient’s grossly reduced ability
to get food and shelter, and the need for diagnostic procedures

• History of rapidly progressing symptoms and the rupture of a patient’s natural

support systems.

• Patients should be committed involuntarily for hospitalization, as they cannot

make decisions because of their slowed thinking, negative Weltanschauung
(world view), and hopelessness
TREATMENT
• Combined treatment ( Medication and Psychotherapy)

• Somatic Treatment: (Pharmacotherapy)

• Objective is to symptoms remission.

• Use of specific pharmacotherapy approximately double the chances that a
depressed patient will recover in 1 month
GENERAL CLINICAL GUIDELINES
• Dosage of anti depressant 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.

• If patient is improving clinically on a low dosage of the drug, this

dosage should not be raised unless clinical improvement stops before
maximum benefit
INITIAL MEDICATION SELECTION
• SSRI is the most commonly used medications for depression.

• Selection of the initial treatment depends on:

• The chronicity of the condition, course of illness,
• Family history of illness and treatment response
• Symptom severity
• Concurrent general medical or other psychiatric conditions
• Prior treatment responses to other acute phase treatments
• Potential drug-drug interactions
• Patients preference
DURATION AND PROPHYLAXIS
• Should maintain anti depressant treatment for at least 6 months or the
length of previous episode, which ever is greater

• One study concluded when episodes are less than 2 ½ years apart,
prophylactic treatment is recommended

• Severity of previous depressive episodes

• Prevention of new mood episodes (i.e., recurrences) is the aim of the

maintenance phase of treatment.
ACUTE TREATMENT FAILURES
• Patient may not respond to medication because,
• They cannot tolerate the side effects, even in the face of an excellent clinical
response
• An idiosyncratic adverse event may occur
• The clinical response is not adequate.
• Wrong diagnosis has been made.
• Acute phase medication trials should last 4-6 weeks to allow for
adequate time and meaningful symptom reduction.
• Partial response: 20-25 percent symptoms reduction
SELECTING SECOND TREATMENT
OPTIONS
• When the initial treatment is unsuccessful, switching to an alternative
treatment or augmenting the current treatment is a standard option.

• The choice between switching from the single initial treatment to a

new single treatment rests on the patient’s prior treatment, the
degree of benefit achieved with the initial treatment, and patients
preference.
• As a rule, switching rather than augmenting is preferred after a initial
medication failure.
SELECTING SECOND TREATMENT
OPTIONS
• When switching from one monotherapy to another, Picking
medications from different class SSRI to SNRI.
• Several antipsychotics, most notably Quetiapine and Aripripazole are
effective for augmentation (meta-analysis best evidence as
augmentation agent)
• Lithium effective for augmenting both SSRIs and TCAs
OTHER SOMATIC TREATMENTS
• Neurostimulation:
• Preliminary study have shown chronic, Recurrent Major Depressive Disorders
went in to remission when treated with Vagus Nerve Stimulation
• Mechanism of action is unknown.
• Transcranial Magnetic Stimulation:
• Repetitive transcranial magnetic stimulation (rTMS) produces focal secondary
electrical stimulation of targeted cortical regions.
• It is non convulsive
• Patient do not require anesthesia or sedation and remain awake and alert, 40
minute Out Patient Procedure, treatment is administered daily for 4-6 weeks
• Contradicted in patients with metallic implants
THANK YOU
THANK YOU