DEPRESSIVE EPISODE Definition Depression also known as depressive

DEPRESSIVE EPISODE

Definition �Depression, also known as depressive disorders or unipolar depression, is a mental illness characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in things that once were pleasurable. Disturbance in sleep, appetite, and mental processes are a common accompaniment.

� According to the National Institute of Mental Health, symptoms of depression may include the following: � difficulty concentrating, remembering details, and making decisions � fatigue and decreased energy � feelings of guilt, worthlessness, and/or helplessness � feelings of hopelessness and/or pessimism � insomnia, early-morning wakefulness, or excessive sleeping � irritability, restlessness � loss of interest in activities or hobbies once pleasurable, including sex � overeating or appetite loss � persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment � persistent sad, anxious, or "empty" feelings � thoughts of suicide, suicide attempts

�Warning signs of suicide with depression include: �a sudden switch from being very sad to being very calm or appearing to be happy �always talking or thinking about death �clinical depression (deep sadness, loss of interest, trouble sleeping and eating) that gets worse �having a "death wish, " tempting fate by taking risks that could lead to death, like driving through red lights �losing interest in things one used to care about

�making comments about being hopeless, helpless, or worthless �saying things like "It would be better if I wasn't here" or "I want out" �talking about suicide (killing one's self) �visiting or calling people one cares about �Remember, if you or someone you know is demonstrating any of the above warning signs of suicide with depression, either call your local suicide hot line, contact a mental health professional right away, or go to the emergency room for immediate treatment.

SOMATIC SYNDROME IN DEPRESSION �A)Significant decrease in appetite or weight. �B)Early morning awakening, at least 2 � (or more) hours before the usual time of awaking. �C)Diurnal variation with depression being worst in the morning. �D)Pervasive loss of interst and loss of reactivity to pleasurable stimuli. �E)Psychomotor agitation or retardation.

�There are two main categories of depression: 1)major depressive disorder and � 2)Dysthymic disorder Others -atypical depresssion -postpartum depression -Bipolar depression -seasonal depression -Psychotic depression

Major depressive disorder To distinguish your condition as major depression, one of your symptoms must be either depressed mood or loss of interest. Also, the symptoms must be present for most of the day every day or nearly every day for at least two weeks.

�Other symptoms include� 1)Fatigue or loss of energy almost every day 2) Feelings of worthlessness or guilt almost every day 3)Impaired concentration, indecisiveness 4)insomnia or hypersomnia (excessive sleeping) almost every day 5) Markedly diminished interest or pleasure in almost all activities nearly every day (called anhedonia, this symptom can be indicated by reports from significant others. )

� 6)Psychomotor agitation or retardation (restlessness or being slowed down) � 7) Recurring thoughts of death or suicide (not just fearing death) � 8)Significant weight loss or gain (a change of more than 5% of body weight in a month)

�Major Depressive Disorder - Epidemiology Lifetime prevalence -women: 10 - 25% -men: 5 - 12 % -pre-pubertal children: boys>girls -puberty to 50 yrs: women 2 x men -after 50 yrs: women=men

Dysthymia depression �Dysthymia, sometimes referred to as chronic depression, is a less severe form of depression. With dysthymia, the depression symptoms can linger for a long period of time, perhaps two years or longer. Those who suffer from dysthymia are usually able to function adequately but might seem consistently unhappy.

symptoms �The symptoms of dysthymia are the same as those of major depression but not as intense and include the following: �Persistent sad or empty feeling �Difficulty sleeping (sleeping too much or too little) �Insomnia (early morning awakening) � Feelings of helplessness, hopelessness, and worthlessness �Feeling of guilt � Loss of interest or the ability to enjoy oneself

�Loss of energy or fatigue � Difficulty concentrating, thinking or making decisions �Changes in appetite (overeating or loss of appetite) �Observable mental and physical sluggishness �Persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment �Thoughts of death or suicide

Organic Illnesses Associated with Depression � Rheumatologic - rheumatoid arthritis, SLE � Cardiac - myocardial infarction, hypertension � Endocrine - hyperthyroidism, hypothyroidism, diabetes mellitus, postpartum state � Gastrointestinal - cirrhosis, inflammmatory bowel disease, pancreatitis, � Hematologic - sickle cell anemia � Nutritional deficiencies - B 12, Folate, iron, thiamine, niacin � Infectious - encephalitis, hepatitis, tuberculosis � Renal - renal transplant, uremia � Neoplastic - Leukemia, � Neurologic - subdural hematoma, multiple sclerosis, CVA, Parkinson’s, � Miscellaneous - psoriasis, sarcoidosis

Depression in Children & Adolescents �Presenting symptoms may include: -sad or irritable mood -loss of interest/pleasure in usual activities -school difficulties -school-refusal -somatic complaints -aggressive/antisocial behavior patterns -weight change or sleep pattern disruption

III)BIPOLAR MOOD(AFFECTIVE)DISORDER �Bipolar disorder is a complex genetic disorder. The mood swings associated with it alternate from major, or clinical, depression to mania or extreme elation. The mood swings can range from very mild to extreme, and they can happen gradually or suddenly within a timeframe of minutes to hours. When mood swings happen frequently, the process is called rapid cycling.

� The clinical depression symptoms seen with bipolar disorder include: � Decreased appetite and/or weight loss, or overeating and weight gain � Difficulty concentrating, remembering, and making decisions � Fatigue, decreased energy, being "slowed down" � Feelings of guilt, worthlessness, helplessness � Feelings of hopelessness, pessimism � Insomnia, early-morning awakening, or oversleeping � Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex � Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain � Persistently sad, anxious, or "empty" moods � Restlessness, irritability � Thoughts of death or suicide, suicide attempts

�The signs of mania with bipolar disorder include: �Disconnected and racing thoughts �Grandiose notions �Inappropriate elation �Inappropriate irritability �Inappropriate social behavior �Increased sexual desire �Increased talking speed and/or volume �Markedly increased energy �Poor judgment �Severe insomnia

SUBTYPE OF BIPOLAR DISORDER � 1)Bipolar I: - Characterized by episodes of severe mania and severe depression. 2)Bipolar II: Characterized by episodes of hypomania(not requiring hospitalization)and severe depression.

�Signs of hypomania with bipolar II disorder include: �Decreased need for sleep �Extreme focus on projects at work or at home �Exuberant and elated mood �Increased confidence �Increased creativity and productivity �Increased energy and libido �Reckless behaviors �Risk-taking behaviors

IV)RECURRENT DEPRESSIVE DISORDER �This disorder is characterized by recurrent(at least two)depressive episodes(unipolar depression). V)PERSISTENT MOOD DISORDER -These disorders are characterized by persistent mood symptoms which last for more than 2 years(1 year in children and adolescents)but are not severe enough to labelled aseven hypomaniac or mild depression.

Prognostic factors in mood disorders �Good: Ø acute onset, Ø typical c/f, Ø severe depression, Ø good premorbid personality, Ø good response to Rx.

�Poor: Ø co-morbid medical disorders, Ø double depression, Ø stress, Ø hypochondriacal features, Ø poor drug compliance

ETIOLOGY The etiology of mood disorders is currently unknown. However several theories have been propounded; These include: 1)Biological theories: The following finding and theories point toward a biological basis of mood disorders. A)Genetic hypothesis: The life time risk for the 1 st degree

relative of Bipolar mood disorder patient is 25%, and Of recurrent depressive disorder patient is 20%. -The life time risk for the children of one patient with mood disorder is 27% and of both parents with mood disorder is 74%. -The concordance rate in bipolar disorders for monozygotic twins is 65% and for dizygotic twins is 20%. -The concordance rate in unipolar depression for monozygotic twins is 46% and for dizygotic twin is 20%.

B)BIOCHEMICAL THEORIES -The mmonoamine hypothesis suggests abnormality in monoamine(catecholamine(norepinephrine and dopamine) and serotonin) system in the central nervous system at one or more sites. C)NEUROENDOCRINE THEORIES - Mood symptoms are prominently present in many endocrine disorders, like hypothyroidism, Cushing’s disease, Addison’s disease. - -Endocrine function is often disturbed in depression with cortisol hypersecretion, non suppresion with dexamethasone challenge, Decreased TSH level,

�Decrease growth hormone production. D)BRAIN IMAGING CT Scan, MRI Scan, PET scan, can be done. -These have yielded inconsistent , yet suggestive findings are: Ventricular dilatation, changes in blood flow and metabolism in several parts of brain, like prefrontal cortex, anterior cingulate cortex, and caudate)

� 2)psychosocial theories a)psychoanalytic theories b)increased stress c)cognitive and behavioral theories.

MANAGEMENT �Antidepressants ØTricyclic Antidepressants (TCAs) ØMonoamine Oxidase Inhibitors (MAOIs) ØSelective Serotonin Reuptake Inhibitors 1)Tricyclic antidepressants: -Imipramine, Amitriptyline

� 2)MAOIs -Moclobemide, clorgyline 3)SSRIs Fluoxetine, Fluvoxamine, paroxetine, sertraline, citalopr am, Escitalopram There are 3 phases of treatment: 1. Acute treatment(till remission occurs) 2. Continuation tretment(from remission till end of treatment) 3. Maintenance treatment(to prevent further recurrences)

�Maintenance treatment may be indicated in the following patient. -partial response to acute treatment. -poor symptom control during the continuation treatment. -more than 3 episodes(90% chances of recurrence) -More than 2 episodes with early age of onset, or recurrence within 2 years of stopping antidepressants, or severe and or life threatening depression, or family history of mood disorder. -chronic depression(>2 years) or double depression.

�About 20 -35%of depressed patients are refractory to antidepressant medication. These patient may require one of the following treatment. -A change of antidepressant. -combination of 2 types of antidepressants. -Augmentation with lithium -ECT One type of depression namely Delusional depression is usually refractory to antidepressant alone. The treatment of choice are: -Antidepressants with ECT -Antidepressants with antipsychotics -Antidepressants with lithium

2)ECT(Electroconvulsive therapy) The indication of ECT in depression are: a)Severe depression with suicidal risk b)Severe depression with stupor, severe psychomotor retardation, or somatic syndrome

�C)Severe treatment refractory depression �d)Delusional depression �e) Presence of significant antidepressant side-effects or intolerance to drugs. The response is rapid, resulting in marked improvement. usually 6 -8 ECTs are needed, given three times a week. ECT can also be used for acute maniac excitement if it is not responding to antipsychotics and lithium.

ANTIPSYCHOTIC DRUGS �The commonly used drugs are risperidone, haloperidol, olanzapine, chlorpromazine. ANTIMANIAC(MOOD STABILIZING) DRUGS lithium -acute phase of mania -prevention of further episodes in bipolar mood disorder.

�SODIUM VALPROATE �-For acute treatment in mania and prevention of bipolar mood disorder. �-particularly useful in those patient who are refractory to lithium. CARBAMAZEPINE AND OXCARBAZEPINE -For acute treatment of mania and prevention of bipolar mood disorder. -particularly in those patient who are refractory to lithium and valproate. LAMOTRIGINE -Bipolar disorder

�BENZODIAZEPINES -clonazepam, lorazepam 3)PSYCHOSOCIAL TREATMENT -A)COGNITIVE BEHAVOUR THERAPY -Aims at correcting the depressive negative ideations e. g. hopelessness, worthlessness, helplessness, and pessimistic ideas and replacing them by new cognitive and behavioral responses. B)INTERPERSONAL THERAPY IPT attempts to recognize and explore interpersonal stressors, social isolation, or social skill deficits which act as precipitants for depression.

�C)BEHAVOUR THERAPY - This includes various short-term modalities like social skills training, problem solving techniques, Activity scheduling, and decision making techniques. D)GROUP THERAPY E)FAMILY THERAPY