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Ten Leading Causes of Disability in the World. Episode Disorder *Major depression episode *Major depression disorder *Major depression episode+ *Bipolar disorder, Type I manic/mixed episode *Manic/mixed episode *Bipolar disorder, Type I

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*Major depression episode *Major depression disorder

*Major depression episode+ *Bipolar disorder, Type I

manic/mixed episode

*Manic/mixed episode *Bipolar disorder, Type I

*Major depressive episode+ *Bipolar disorder, Type II

hypomanic episode

*Chronic subsyndromal *Dysthymic Disorder


*Chronic fluctuations

between subsyndromal *Cyclothymic disorder

depression & hypomania

  • Mood - a person’s sustained emotional state
  • Affect – the outward manifestation of a person’s feelings, tone, or mood
major depression
Major Depression
  • Syndromal classification with disturbances of mood, neurovegetative and cognitive functioning
major depression6
Major Depression

At least 5 of the following symptoms present for at least 2 weeks (either #1 or #2 must be present):

1) depressed mood

2) anhedonia – loss of interest or pleasure

3) change in appetite

4) sleep disturbance

major depression7
Major Depression

5) psychomotor retardation or agitation

6) decreased energy

7) feeling of worthlessness or inappropriate guilt

8) diminished ability to think or concentrate

9) recurrent thoughts of death or suicidal ideation

major depression8
Major Depression
  • Symptoms cause marked distress and/or

impairment in social or occupational functioning.

  • No evidence of medical or substance-induced etiology for the patient’s symptoms.
  • Symptoms are not due to a normal reaction to the death of a loved one.
bereavement and late life depression
Bereavement and Late Life Depression
  • 25 – 35% of widows/widowers meet diagnostic criteria for major depressive disorder at 2 months.
  • ~15% of widows/widowers meet diagnostic criteria for major depressive disorder at one year.
  • This figure remains stable throughout the second year.
subtypes of depression
Subtypes of Depression
  • Atypical
    • Reverse neurovegetative symptoms
    • Mood reactivity
    • Hypersensitivity to rejection
    • MAO-I’s and SSRI’s are more effective treatments
subtypes of depression11
Subtypes of Depression
  • Psychotic (~10% of all MDD)
    • Delusions common, may have hallucinations
    • Delusions usually mood congruent
    • Combined antidepressant and antipsychotic therapy or ECT is necessary
subtypes of depression12
Subtypes of Depression
  • Melancholic
    • No mood reactivity
    • Anhedonia
    • Prominent neurovegetative disturbance
    • More likely to respond to biological treatments
subtypes of depression13
Subtypes of Depression
  • Seasonal
    • Onset in Fall, remission in Spring
    • Hypersomnia is typical
    • Less responsive to medications
    • A.M. light therapy (>2,500 lux) is effective
subtypes of depression14
Subtypes of Depression
  • Catatonic
    • Motoric immobility (catalepsy)
    • Mutism
    • Ecolalia or echopraxia

Point prevalence

  • 6 – 8% in women
  • 3 – 4% in men

Lifetime prevalence

  • 20% in women
  • 10% in men

Age of Onset

  • Throughout the life cycle, typically from the mid 20’s through the 50’s with a peak age of onset in the mid 30’s


  • More prevalent in first degree relatives

3-5x the general population risk

  • Concordance is greater in monozygotic than dizygotic twins
  • Increased prevalence of alcohol dependence in relatives

Original, clearly over simplistic theories regarding norepinephrine and serotonin

  • Deficiency states depression
  • States of excess mania
problems with initial theories
Problems with initial theories
  • Inconsistent findings when studying measures of these systems: MHPG (3 methoxy 4 hydroxyphenolglycol) and 5HIAA (5 hydroxy indoleacetic acid) in the urine and CSF.
  • Treatments block monoamine uptake acutely, however the positive effects occur in 2-4 weeks.
receptor theory more useful
Receptor theory more useful
  • Antidepressant treatment causes a down regulation in central adrenergic and serotonergic receptors
    • This change corresponds temporally to the antidepressant response
  • Hyperactivity of HPA axis:
    • Elevated cortisol
    • Nonsuppression of cortisol following dexamethasone
    • Hypersecretion of CRF
  • Blunting of TSH response to TRH
  • Blunting of serotonin mediated increase in plasma prolactin
  • Blunting of the expected increase in plasma growth hormone response to alpha-2 agonists
functional neuroimaging pet spect demonstrates decreased metabolic activity in
Functional Neuroimaging (PET,SPECT)demonstrates decreased metabolic activity in
  • Dorsal prefontal cortex
    • Anterolateral (concentration, cognitive processing)
    • Cingulate (regulation of mood and affect)
  • Subcortical
    • Caudate (psychomotor changes)
  • Risk Factors
    • Poor social supports
    • Early parental loss
    • Introversion
    • Female gender
    • Recent stressor (especially medical illness)
  • Cognitive Theory
    • Patients have distorted perceptions and thoughts of themselves, the world around them and the future
  • Possible to treat by restructuring
secondary causes of depression
Secondary Causes of Depression
  • Toxic
  • Endocrine
  • Vascular
  • Neurologic
  • Nutritional
  • Neoplastic
  • Traumatic
  • Infectious
  • Autoimmune
depression differential diagnosis
Depression – Differential Diagnosis

Other Mood Disorders

  • Adjustment Disorder with Depressed Mood
    • Maladaptive and excessive response to stress, difficulty functioning, need support not medicines, resolve as stress resolves
    • Dysthymic Disorder
    • Bipolar Disorder
  • Other Psychotic Disorders – if psychotic subtype
  • Personality Type – “glass is half empty type” overall pessimistic, depressed outlook. Chronic and longstanding with no change in function.


  • Tricylclic antidepressants
  • Monoamine oxidase inhibitors
  • Second generation antidepressants
    • SSRI’s, Venlafaxine, bupropion, martazapine
  • Electoconvulsive therapy

Psychosocial Treatments

  • Education
  • Specific pscychotherapies
  • Vocational training
  • Exercise

When to Refer?

  • Question regarding suicide risk
  • Presence of psychotic symptoms
  • Past history of mania
  • Lack of response to adequate medication trial


  • One episode – 50% chance of reoccurence
  • Two episodes – 70% chance of reoccurence
  • Three or more episodes - >90% chance of reoccurence
dysthymic disorder
Dysthymic Disorder


  • Chronically depressed mood for most of the day, more days than not, for at least two years. Can be irritable mood in children and adolescents for 1 year
  • While depressed, presence of at least two of the following
    • Poor appetite or overeating
    • Sleep disturbance
    • Low energy or fatigue
    • Low self esteem
    • Poor concentration
    • Feelings of hopelessness
dysthymic disorder35
Dysthymic Disorder
  • Never without depressive symptoms for over 2 months
  • No evidence of an unequivocal Major Depressive Episode during the first two years of the disturbance (1 year in children and adolescents)
  • No manic or hypermanic episodes
  • Not superimposed on a chronic psychotic disorder
  • Not due to the direct physiologic affects of a substance or a general medical condition
  • More prevalent in women, 4% prevalence in women, 2% in men
  • Onset is usually in childhood, adolescence or early adulthood
  • Often is a superimposed Major Depression
  • High prevalence of substance abuse in this group
differential diagnosis
Differential Diagnosis
  • Other mood disorders
  • Mood disorder due to a general medical condition
  • If no superimposed Major Depression
    • Psychotherapy
  • Some evidence suggest responsiveness to antidepressant medication

Prognosis is not as good as Major Depression in terms of total symptoms remission

bipolar disorder
Bipolar Disorder

Characteristics of a Manic Episode

  • A distinct period of abnormally and persistently elevated, expansive or irritable mood
  • During the period of mood disturbance, at least three of the following symptoms have persisted (four if the mood is only irritable) and have been persistent to a significant degree
    • Inflated self esteem or grandiosity
    • Decreased need for sleep
    • More talkative than usual or pressure to keep talking
    • Flight of ideas or subjective experience that thoughts are racing
characteristics cont
Characteristics (Cont.)
  • Distractability, i.e. attention too easily drawn to unimportant or irrelevant external stimuli
  • Increase in goal-directed activity or psychomotor agitation
  • Excessive involvement in pleasurable activities which have a high potential for painful consequences, e.g. unrestrained buying sprees, sexual indiscretions, or foolish business investments
characteristics cont43
Characteristics (Cont.)
  • Mood disturbance sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relations with others, or to necessitate hospitalization to prevent harm to self or others
  • At no time during the disturbance have there been delusions or hallucinations for as long as two weeks in the absence of prominent mood symptoms
  • Not superimposed on schizophrenia, schizophreniform disorder, or delusional disorder or psychotic disorder NOS
  • The disturbance is not due to the physiologic effects of a substance or general medical disorder
  • Type I - manic/mixed episode +/- major depressive episode
  • Type II - hypomanic episode + major depressive episode

Lifetime prevalence

  • Type I - 0.7 - 0.8%
  • Type II - 0.4 - 0.5%
    • Equal in males and females
    • Increased prevalence in upper socioeconomic classes
  • Age of Onset
    • Usually late adolescence or early adulthood. However some after age 50. Late onset is more commonly Type II.
  • Greater risk in first degree relatives

(4-14 times risk)

  • Concordance in monozygotic twins >85%
  • Concordance in dyzygotic twins – 20%
secondary causes of mania
Secondary Causes of Mania


  • Drugs of Abuse
    • Stimulants (amphetamines, cocaine)
    • Hallucinogens (LCD, PCP)
  • Prescription Medications
    • Common: antidepressants, L-dopa, corticosteroids


  • Right-sided CVA
  • Right frontotemporal tumors
  • Huntington’s Disease
  • Multiple Sclerosis
secondary causes of mania cont
Secondary Causes of Mania(Cont.)


  • Neurosyphilis
  • HIV


  • Hypothyroidism
  • Cushing’s Disease

Cyclothymic Disorder

Other Psychotic Disorders

  • Education and Support
  • Medication
    • Lithium
    • Carbamazepine
    • Valproate
    • Lamotrigine
    • ECT
  • Acute Episode
    • Manic - 5 weeks
    • Depressed - 9 weeks
    • Mixed - 14 weeks
  • Long Term
    • Variable - most cover fully
    • Mean number of lifetime episodes 8-9
cyclothymic disorder
Cyclothymic Disorder


  • For at least two years (one for children and adolescents) presence of numerous Hypomanic Episodes and numerous periods with depressed mood or loss of interest or pleasure that did not meet criterion A of a Major Depressive Episode
  • During a two year period (one year in children and adolescents) of the disturbance, never without hypomanic or depressive symptoms for more than a two month time
characteristics cont53
Characteristics (Cont.)
  • No clear evidence of a Major Depressive Disorder, or Manic Episode during the first two years of the disturbance (or one year for children and adolescents)
  • Not superimposed on a chronic psychotic disorder, such as schizophrenia or Delusional Disorder
  • Not due to the direct physiologic affects of a substance or a general medical condition
  • Lifetime prevalence 0.4 – 1.0 %

same for males and females

  • Age of onset
    • Usually in adolescence or early adulthood
  • Genetics
    • Major Depression and Bipolar Disorder more common in first degree relatives
cyclothymic disorder55
Cyclothymic Disorder

Secondary causes of cyclothymic disorder

  • Bipolar Disorder
  • Mood disorders due to a general medical condition


  • Initiation of biologic treatment is dependent on the degree of impairment
  • If treatment is indicated, it is similar to that of Bipolar Disorder

*Major depression episode *Major depression disorder

*Major depression episode+ *Bipolar disorder, Type I

manic/mixed episode

*Manic/mixed episode *Bipolar disorder, Type I

*Major depressive episode+ *Bipolar disorder, Type II

hypomanic episode

*Chronic subsyndromal *Dysthymic Disorder


*Chronic fluctuations

between subsyndromal *Cyclothymic disorder

depression & hypomania