Depression there are at least two sides to every story
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Depression—There are at least two sides to every story. Depression. It’s not only a state of mind. The symptoms of depression. Reference: Adapted from

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Depression—There are at least two sides to every story.

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Depression—There are at least two sides to every story.

Depression. It’s not only a state of mind.

The symptoms of depression

Reference: Adapted from

American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition,Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489.

Depression – the physical presentation

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 compliant1

N = 1146 Primary care patients with major depression

  • Reference:

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

Aches/pain – a physical symptom of significance

Aches/Pain as common as anxiety among depressed patients

Adapted from

1.Silverstein B.Am J Psychiatry. 1999;156(3):480-482. 2.Silverstein B. Am J Psychiatry. 2002;159(6):1051-1052.

The importance of emotional and physical symptoms

  • 76% of compliant depressed patients with lingering symptoms of depression relapsed within 10 months1*

94% of depressed patients who experienced lingering symptoms had mild to moderate physical symptoms1

*Psychiatric inpatients and outpatients.

  • Reference:

  • Adapted from: Paykel ES, et al.Psychol Med. 1995;25:1171-1180.

Serotonin5HT and NorepinephrineNE in the brain

Limbic System

Prefrontal Cortex

Locus Ceruleus (NE Source)

Raphe Nuclei (5-HT source)

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







There are at least two sides to the neurotransmitter story

Functional domains of Serotonin and Norepinephrine1-4

  • Both serotonin and norepinephrine mediate a broad spectrum of depressive symptoms

Serotonin (5-HT)

Norepinephrine (NE)

Depressed Mood



Thought process

Vague Aches and pain

  • References:

  • Adapted from: Stahl SM. In: Essential Psychopharmacology: Neuroscientific Basis and Practical Applications: 2nd ed. Cambridge University Press 2000.

  • Blier P, et al.J Psychiatry Neurosci. 2001;26(1):37-43.

  • Doraiswamy PM.J Clin Psychiatry. 2001;62(suppl 12):30-35.

  • Verma S, et al.Int Rev Psychiatry. 2000;12:103-114.

The neurotransmitter pathway story

It’s not all in your head

  • Dysregulation of Serotonin (5HT) and Norepinephrine (NE) in the brain are strongly associated with depression

  • Dysregulation of 5HT and NE in the spinal cord may explain an increased pain perception among depressed patients1-3

  • Imbalances of 5HT and NE may explain the presence of both emotional and physical symptoms of depression.

Descending Pathway





Ascending Pathway

  • Adapted from References:

  • Stahl SM.J. Clin Psych. 2002;63:203-220.

  • Verma S, et al.Int Rev Psychiatry. 2000;12:103-114.

  • Blier P, et al.J Psychiatry Neurosci. 2001;26(1):37-43.

Depression: Current treatment outcomes1

  • Up to 70% of depressed patients respond ( 50% decrease in HAM-D score) to treatment but fail to achieve remission from their emotional and physical symptoms1*

  • Approximately 30% of depressed patients achieve remission ( 7 score on the HAM-D) with treatment1*

* Antidepressant clinical drug trials.


1. O’Reardon JR, et al.PsychiatrAnn. 1998;28:633-640.

Response and Remission defined

Hamilton Depression Rating Scale (HAM-D): 17 Items, Total Score 0 - 52

HAM-D17 Scores


(Major Depressive Disorder)


  • Response

  •  50% reduction from baseline HAM-D score

  • Remission: HAM-D Score  7



1. Frank E. Conceptualization and rationale for consensus definition terms in MDD, Arch Gen Psych. 1991; 48:851-855.




Social Adjustment Scale-SR (Mean ± SD)







Remission (n=202)





Treatment outcome:Effect on work & social functioning

Remitted patients virtually equaled healthy controls on functioning levels at endpoint of 12-week treatment trial (Responders & non-responders did not)

Higher Score indicates greater impairment

Study in chronic depressed patients

*p.05 vs nonresponse. **p.05 vs response.

Miller IW, et al. J Clin Psychiatry. 1998;59(11):608-619.

Many depressed patients are still depressed.

Depressed patients continue to have needs that are not being fully addressed1

  • Depressed patients present with emotional and physical symptoms.

  • Approximately 30% of depressed patients achieve remission in clinical trials2*

  • Up to 70% of patients who respond fail to remit2*

  • Incomplete relief from symptoms may increase the risk of relapse2,3

  • Lingering emotional and physical symptoms may jeopardize achieving remission.

  • References:

  • Nierenberg AA, et al.J Clin Psychiatry. 1999:60(suppl 22):7-11.

  • O’Reardon JR, et al.PsychiatrAnn. 1998;28:633-640.

  • Lynch ME.J Psychiatry Neurosci. 2001;26(1):30-36.

*In antidepressant clinical drug trials.

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