Depression
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Depression. SYMPTOMS. Depressed mood. Markedly diminished interest or pleasure in activities. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite. Insomnia or hypersomnia . Psychomotor agitation or retardation. Fatigue or loss of energy.

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Depression

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Depression

Depression


Depression

SYMPTOMS

  • Depressed mood.

  • Markedly diminished interest or pleasure in activities.

  • Significant weight loss when not dieting or weight gain, or decrease or increase in appetite.

  • Insomnia or hypersomnia.

  • Psychomotor agitation or retardation.

  • Fatigue or loss of energy.

  • Feelings of worthlessness.

  • Diminished ability to think or concentrate.


Depression

EPIDEMIOLOGY

  • Demographics

    • About 5 out of 100 suffer from major depression.

    • A further 5 out of 100 suffer from milder forms of depression at some time in their lives.

  • Gender

    • Females (8-10% probability) are more prone to depression than males. (3-5% probability)

  • Race

    • In DALYs, Caucasians tend to have more depressive episodes, followed by East Asians, and then Africans.

    • Philippines is 93rd country

  • Social Status

    • More common among divorced or separated people.

    • No correlation between socioeconomic status and depression.


Depression

CAUSES

  • For many, there is an obvious cause for depression, such as:

    • Physical illness

    • Illness of death of relative

    • Stress, overwork, or unemployment.

  • However, somebody can get depression withoutany apparent cause.

  • When someone gets depressed, their reaction to events like these is much more intense and lasting than it is to be expected.


Depression

BIOLOGICAL CAUSE

  • Biological: Monoamine hypothesis

    • Primarily happens in the limbic areas.

    • One of the function of serotonin is to regulate other neurotransmitter systems – decreased serotonin activity in the post-synaptic cleft allows the NT system to act in erratic ways.

    • Depression arises when low serotonin levels promote low levels of Norepinephrine.

      • Some antidepressants enhance NE levels, while others raise dopamine levels.


Depression

BIOLOGICAL CAUSE

  • Biological: Neuroanatomic incongruence

    • Increased volume of lateral ventricles, with smaller volumes of basal ganglia, thalamus, hippocampus, and frontal lobe.

    • Neurogenesis is impaired due to decreased Brain-derived neurotrophic factor (BDNF).

  • Biological: Hormonal

    • Increased cortisol levels and enlarged pituitary and adrenal glands are suggested to play a role in depression.

    • This is caused by oversecretion of corticotropin-releasing hormone from the hypothalamus.


Depression

BIOLOGICAL CAUSE

  • Biological: Cytokines

    • Symptoms of depression are similar to general illness, and may result from abnormalities in cytokines (esp. IL-6 and TNF-a)..

  • Genetic Concordance

    • Among monozygotic twins, 40-71% chance that the other twin will have depression if one twin is depressed.

    • Among dizygotic twins it is 3-13%.


Depression

PSYCHOLOGICAL CAUSE

Negative emotionality is a common precursor. Adverse events and a person’s way of coping or reacting to them determines resilience which may help prevent depression.

Low self-esteem and self-defeating or distorted thinking are also related to depression.

Depression is less likely to occur among people who have a sense of religiosity


Depression

PSYCHOLOGICAL CAUSE

  • Psychological: Psychodynamic

    • Depression is a result of a person’s early experiences in life (Sigmund Freud).

    • Attachment Theory predicts relationship between depression and quality of earlier bond between infant and their adult caregiver.

  • Psychological: Humanistic

    • Depression arises when people are unable to attain their needs or to self-actualize (Abraham Maslow).


Depression

PSYCHOLOGICAL CAUSE

  • Psychological: Cognitive -Behavioral

    • According to Aaron Beck, three concepts underlie depression:

      • Triad of negative thoughts composed of cognitive errors about oneself, one’s world, and one’s future;

      • Recurrent patterns of depressive thinking;

      • Distorted information processing.

    • Learned Helplessness (Martin Seligman).

      • Humans remain in unpleasant situations even when they are able to escape because they initially had no control.


Depression

PSYCHOLOGICAL CAUSE

  • Psychological: Cognitive -Behavioral

    • Depressed individuals have negative beliefs about themselves which is based on initial experiences of loss, failure, and even on their emotional and physical states – all these result to a negative self concept and lack of self-efficacy (Albert Bandura).


Depression

SOCIAL CAUSE

Certain social situations such as poverty, social isolation, and child abuse are associated with increased risk of developing depressive disorders.

Among children, disturbances in family functioning serve as risk factors for depression; among adults, stressful life events are strongly associated with onset of depression


Depression

SUBTYPES OF DEPRESSION

Melancholic Depression

Loss of pleasure in most or all activities, a failure of reactivity to pleasurable stimuli, worsening of symptoms during morning hours, psychomotor retardation, and excessive weight loss.

Atypical Depression

Mood reactivity, significant weight gain or increased appetite, excessive sleep or sleepiness, sensation of heaviness in limbs, and significant social impairment due to perceived interpersonal rejection.


Depression

SUBTYPES OF DEPRESSION

Catatonic Depression

Severe form of Depression involving disturbances of motor behavior. Patient may be mute, stuporous, immobile, or exhibit purposeless movements.

Postpartum Depression

Intense and sustained depression experienced by women after giving birth, with an incidence rate of 10-15%.


Depression

SUBTYPES OF DEPRESSION

Seasonal Affective Disorder

Form of depression in which symptoms come during winter or autumn. And disappear during spring. Diagnosis is made if at least two episodes occurred in colder months with none at other months, over a two year period.


Depression

TREATMENT

ANTI-DEPRESSANTS

Selective Serotonin Reuptake Inhibitors

Mechanism: SSRIs inhibit reuptake of serotonin, and make it stay in the synaptic cleft longer than usual, hence repeatedly stimulating the receptors of recipient cell.

Examples: Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), Escitalopram

Serotonin-Norepinephrine Reuptake Inhibitors

Mechanism: SNRIs have the same mechanism as SSRI.

Examples: Venlafaxine, Desvenlafaxine, Duloxetine


Depression

TREATMENT

  • ANTI-DEPRESSANTS

  • Tricyclic Antidepressants (“pramines”)

  • Mechanism: Similar to SNRis, with affinity as antagonists to 5-HT2, 5-HT7, a1 adrenergic, and NMDA receptors.

  • Examples: Amitryptyline, Clomipramine

  • Monoamine Oxidase Inhibitors

  • Mechanism: Inhibit monoamine oxidase, hence preventing breakdown of serotonin, norepinephrine, and dopamine.

  • Examples: Hydralazine, Iproniazid


Depression

TREATMENT

  • PSYCHOLOGICAL TREATMENTS

  • Psychoanalysis

  • Uncover childhood trauma and awareness of self-directed rage.

  • Cognitive-Behavioral Therapy

  • Make patient aware of distorted cognition or overgeneralizations. Replace these with realistic adaptive ones. Focus on the person’s strength.

  • Interpersonal Therapy

  • Make patients more socially adept through uncovering of personal resources and strengths.

  • Logotherapy

  • Addresses existential vaccum associated with feelings of futility and meaninglessness.


Depression

TREATMENT

Electroconvulsive Therapy

Electricity is seen through brain via two electrodes to induce seizure while patient is under anesthesia.

It is the treatment of choice in catatonic depression or when a person has severe anorexia or is suicidal.

Relapse rate is around 50%-84%, but is reduced with use of psychiatric medications or with further ECT.


Depression

COURSE AND PROGNOSIS

Course

Can occur anytime, but usually before age 40. Untreated Depression usually lasts 6-13 months, while treated cases last 3 months.

Prognosis

50% recover within first year.

25% recover within first six months.

50-75% relapse within next five years.

Good Prognostic Indicators

Mild episodes (lasting around month or two)

Absence of psychotic or other comorbid psychiatric symptoms.

Short hospital stay.

Solid family function, friends, and sociality.

Advanced age of onset.


Depression

OTHER CULTURE-BOUND MOOD DISORDERS

Ataque de Nervios: uncontrollable shouting, attacks of crying, trembling, heat rising in chest, aggression.

Piblokto: hysteria, depression, coprophagia, insensitivity to cold, echolalia

Hikikomori: withdrawal from society, seeking isolation; sometimes can be violent.

Hwabyeong: depression, sleeplessness, anxiety, obsessive-compulsiveness, anorexia, paranoia, sleeplessness, irritability.

Shenjingshuairuo: elements of depression and anxiety disorder, such as fatigue, dizziness, sleepiness, irritability, and memory loss.


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