Depression

Introduction
• Depression, also known as Major Depressive Disorder (MDD), is a mood disorder characterized by persistent
feelings of sadness, hopelessness, and a lack of interest or pleasure in nearly all activities. It affects how
individuals think, feel, and behave and can interfere with daily functioning.

 According to the World Health Organization (WHO), depression is one of the leading causes of disability
worldwide. Over 300 million people of all ages suffer from depression globally.

 Women are more likely to experience depression than men. Hormonal changes related to menstruation,
pregnancy, postpartum periods, and menopause can increase vulnerability.
 Clinical features/ Symptoms
A Emotional Symptoms

 Sadness or Depressed Mood: A feeling of deep sadness or emptiness most of the day, nearly every day,
often without any clear external cause.

 Loss of Interest (Anhedonia): Lack of enjoyment or interest in activities previously considered enjoyable
(e.g., hobbies, social activities, sexual activities).

 Feelings of Worthlessness or Guilt: People with depression often feel they are a burden to others or
that they are inadequate, even in situations where this is objectively untrue.
B Cognitive Symptoms

 Rumination: A repetitive, negative thought process focused on perceived failures or problems,

which can exacerbate depressive symptoms.

 Cognitive Distortions:
o All-or-nothing thinking: Viewing situations in extreme, black-and-white terms.
o Overgeneralization: Assuming a single negative event will repeat in other areas of life.
o Catastrophizing: Expecting the worst possible outcome in every situation.

 Suicidal Ideation: Recurrent thoughts of death or suicide, which can range from passive thoughts
(wishing to be dead) to active planning of suicide. This is considered one of the most serious
symptoms requiring immediate intervention.
C. Physical Symptoms

 Sleep Disturbances:
o Insomnia: Difficulty falling asleep, staying asleep, or waking up too early.

o Hypersomnia: Sleeping excessively, yet still feeling fatigued or unrefreshed.

 Appetite Changes: Either a loss of appetite, leading to weight loss, or increased cravings (often for carbohydrate-rich foods),
leading to weight gain.

 Low Energy/Fatigue: Feeling physically drained even after minimal activity. This can be so profound that it impairs the ability to
perform daily tasks like personal hygiene or cooking.

 Psychomotor Changes:
o Psychomotor retardation: Slowing down of thought processes, speech, and physical movement.

o Psychomotor agitation: Restlessness or inability to sit still, sometimes manifested by pacing or fidgeting.
D Social and Occupational Dysfunction

 Decreased Productivity: Difficulty concentrating, completing tasks, or making decisions can lead to impaired
work or academic performance.

 Social Withdrawal: Avoiding social interaction, even with close friends and family, due to a lack of energy or
interest.
 Diagnostic Criteria (DSM 5 TR)
A. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous
functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

NOTE: Do not include symptoms that are clearly attributable to another medical condition.

1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad, empty, hopeless) or
observations made by others (eg, appears tearful). (NOTE: In children and adolescents, can be irritable mood.)

2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either
subjective account or observation).
3) Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of body weight in a month), or decrease or
increase in appetite nearly every day. (NOTE: In children, consider failure to make expected weight gain.)
4) Insomnia or hypersomnia nearly every day.
5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being
slowed down).
6) Fatigue or loss of energy nearly every day.
7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or
guilt about being sick).
8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by their subjective account or as observed by
others).
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific
plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
C. The episode is not attributable to the direct physiological effects of a substance or to another medical
condition.
NOTE: Criteria A through C represent a major depressive episode.

NOTE: Responses to a significant loss (eg, bereavement, financial ruin, losses from a natural disaster, a
serious medical illness or disability) may include the feelings of intense sadness, rumination about the
loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive
episode. Although such symptoms may be understandable or considered appropriate to the loss, the
presence of a major depressive episode in addition to the normal response to a significant loss should
also be carefully considered. This decision inevitably requires the exercise of clinical judgement based on
the individual's history and the cultural norms for the expression of distress in the context of loss.

D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified
schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic or hypomanic episode.

Prevalence of Major Depressive Episode Among
Adults

• An estimated 3.8% of the population experience depression, including 5% of

adults (4% among men and 6% among women), and 5.7% of adults older than 60
years.
• Approximately 280 million people in the world have depression
• The prevalence of major depressive episode was higher among adult
females (10.3%) compared to males (6.2%). Depression is about 50% more
common among women than among men. Worldwide, more than 10% of
pregnant women and women who have just given birth experience depression
• The prevalence of adults with a major depressive episode was highest
among individuals aged 18-25 (18.6%).
• The prevalence of major depressive episode was highest among those who
report having multiple (two or more) races (13.9%).
• More than 700 000 people die due to suicide every year. Suicide is the fourth
leading cause of death in 15–29-year-olds.
 Etiology (Causes) of Depression
• A. Biological Factors

 Genetic Predisposition: Individuals with a family history of depression are at higher risk of developing the condition.
Twin studies suggest a heritability estimate of around 40-50% for major depression.

 Neurotransmitter Imbalance: Abnormalities in brain chemicals like serotonin, norepinephrine, and dopamine are
linked to depression. These neurotransmitters regulate mood, motivation, and emotional responses.
o Serotonin: Known as the "feel-good" neurotransmitter, it plays a key role in mood stabilization. Low levels of
serotonin are strongly associated with depressive symptoms.
o Dopamine: Associated with the brain's reward system. Low dopamine levels contribute to anhedonia, or the
inability to feel pleasure.
. Brain Structure and Function:
o Prefrontal Cortex: Responsible for decision-making and regulating
emotions. Studies have found reduced activity in this area in individuals
with depression.
o Hippocampus: Responsible for memory and learning. It is often smaller in
people with depression, potentially due to chronic stress or high levels of
cortisol (the stress hormone).
o Amygdala: Involved in emotional processing and responses to stress.
Overactivity in the amygdala can lead to heightened emotional responses
like fear and sadness.
B. Psychological Factors

 Stress and Trauma: Adverse childhood experiences (e.g., abuse, neglect, or parental loss) significantly
increase the likelihood of developing depression in adulthood. Stressful life events (e.g., the death of a
loved one, job loss, or divorce) can also trigger depressive episodes.

 Cognitive Vulnerabilities: The cognitive model of depression, developed by Aaron Beck, proposes that
individuals with depression exhibit a "negative cognitive triad"—negative views of themselves, the world,
and the future. These negative beliefs often drive and sustain depressive symptoms.

 Personality Factors: Certain personality traits, such as neuroticism (a tendency to experience negative
emotions), perfectionism, and low self-esteem, can increase susceptibility to depression.
C. Environmental Factors
 Socioeconomic Status: Individuals living in poverty or with financial difficulties are more
likely to develop depression due to chronic stress, lack of access to healthcare, and
limited social support.
 Social Isolation: Lack of meaningful relationships or a strong support system can lead to
feelings of loneliness and increase vulnerability to depression.
 Substance Use: Alcohol and drug abuse are common in individuals with depression.
Substance use can exacerbate symptoms and complicate treatment.
 Clinical Picture (Course and Prognosis)
• A. Onset:
• The onset of depression can be gradual or sudden. Some individuals may experience a single episode following a
major life stressor, while others may experience recurrent episodes.
 For some, early symptoms like irritability, anxiety, or changes in sleep patterns may be overlooked, leading to a
delay in diagnosis.
• B. Duration:
 A major depressive episode must last for at least two weeks for a diagnosis, but many episodes can last several
months or longer.
 Persistent depressive disorder (dysthymia) involves chronic depressive symptoms lasting for at least two years,
though they may not be as severe as in major depressive episodes.
• C. Course:
 Episodic: Depression can occur in discrete episodes, with periods of remission in between.
 Chronic: In some cases, depression becomes a chronic condition, where symptoms are present for

long periods.
 Relapsing and Remitting: Many individuals experience recurrent episodes of depression, with each

subsequent episode potentially increasing in severity or duration if left untreated.

• D. Complications:
 Depression can worsen over time if untreated, leading to more severe symptoms and greater
impairment in daily functioning.
 It can increase the risk of substance use disorders, anxiety disorders, and other mental health
conditions.
 Chronic depression is associated with physical health issues, such as cardiovascular disease and a
weakened immune system.
 Treatment of Depression
A. Psychotherapy

 Cognitive Behavioral Therapy (CBT): A time-limited, structured therapy that focuses on changing negative thought
patterns (cognitive distortions) and behaviors. It has strong evidence supporting its effectiveness for depression.
o Techniques include cognitive restructuring (identifying and challenging negative thoughts), behavioral activation
(engaging in activities to improve mood), and problem-solving.

 Interpersonal Therapy (IPT): Focuses on improving relationships and social functioning. It helps individuals address
interpersonal problems, such as grief, role transitions (e.g., job change), and conflicts with others.

 Mindfulness-Based Cognitive Therapy (MBCT): Combines mindfulness practices with cognitive therapy. It is particularly
effective in preventing relapse in people with recurrent depression by teaching them how to manage negative thoughts
non-judgmentally.

 Psychodynamic Therapy: Aims to uncover unconscious conflicts and past experiences that may be contributing to
depression. It is often longer-term but can provide insight into the deeper roots of depression.
B. Pharmacotherapy

 Antidepressants:
o Selective Serotonin Reuptake Inhibitors (SSRIs): First-line treatment for depression (e.g., fluoxetine,
sertraline). SSRIs work by blocking the reabsorption of serotonin, increasing its availability in the brain.
o Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): These drugs affect both serotonin and
norepinephrine, improving mood and energy levels (e.g., venlafaxine, duloxetine).
o Tricyclic Antidepressants (TCAs): An older class of drugs that affect serotonin and norepinephrine but
have more side effects (e.g., amitriptyline).
o Monoamine Oxidase Inhibitors (MAOIs): Rarely prescribed due to dietary restrictions and side effects
but used in treatment-resistant cases (e.g., phenelzine).

 Other Medications:
o Atypical Antidepressants: Includes medications like bupropion, which does not affect serotonin and is
often used when SSRIs are ineffective or poorly tolerated.
o Augmentation Therapy: In treatment-resistant depression, other medications like mood stabilizers
(e.g., lithium) or antipsychotics may be added.
C. Electroconvulsive Therapy (ECT)
 Used in severe cases of depression, particularly when rapid improvement is
needed (e.g., in suicidal patients) or when other treatments have failed.
 ECT involves delivering controlled electric currents to the brain, inducing a brief
seizure. This treatment can result in significant symptom relief, though there can
be side effects like memory loss.
D. Lifestyle and Self-Care Interventions

 Exercise: Physical activity releases endorphins, which can improve mood and reduce symptoms of
depression. Regular exercise is particularly beneficial for mild to moderate depression.

 Diet: A balanced diet, rich in omega-3 fatty acids (found in fish), vitamins (especially B vitamins
and vitamin D), and minerals (e.g., magnesium), supports brain function and mental health.

 Sleep Hygiene: Maintaining a regular sleep schedule, creating a relaxing bedtime routine, and
improving the sleep environment can help reduce symptoms.

 Social Support: Strong relationships with friends, family, or support groups can help buffer against
stress and provide emotional support.
E. Complementary and Alternative Therapies

 Mindfulness Meditation: Involves focusing attention on the present moment without judgment. It helps
reduce stress and improves emotional regulation.

 Yoga and Relaxation Techniques: Practices that combine physical postures, breathing exercises, and
meditation can help reduce stress, improve mood, and increase overall well-being.

 Light Therapy: Used mainly for Seasonal Affective Disorder (SAD), light therapy involves exposure to a lightbox
that mimics sunlight, helping regulate the body's circadian rhythm.
 CASE STUDY (for practice)
• Presenting Complaint: Sarah sought therapy after experiencing a prolonged period of sadness, lack of motivation, and
difficulty in her work. Over the past six months, Sarah reported feeling "numb" and had lost interest in activities she
once enjoyed, including reading, socializing with friends, and going to the gym. She described feeling "constantly
exhausted" despite getting enough sleep. She had started missing deadlines at work, which led to concerns from her
supervisor. She mentioned that she felt "worthless" and often had intrusive thoughts about how much easier life would
be if she weren’t around, though she had not made any active suicide plans. Sarah described feeling increasingly
isolated, as she had been avoiding friends and cancelling plans to stay home. She felt a sense of guilt about her inability
to "pull herself together."

• History of Present Illness: Sarah reported that her symptoms began six months ago, but she had been feeling “off” for
about a year, starting with trouble sleeping and periodic feelings of sadness. She attributed the worsening of her
symptoms to a series of life events: Work-related stress: Sarah was recently passed over for a promotion at work, which
made her feel undervalued and increased her self-doubt. Breakup: A significant relationship ended around the same
time, which deeply affected her self-esteem and left her feeling isolated.
• Family issues: Sarah described a complicated relationship with her mother, stating that she
often felt criticized and unsupported, which worsened her feelings of inadequacy.
• Medical and Psychiatric History: Medical: Sarah has no significant medical history and is
physically healthy. Psychiatric: She mentioned having brief periods of sadness in the past,
particularly in her teenage years, but had never sought treatment for mental health issues
before. Her family had no known history of psychiatric illness.

Questions:

1. Explain the symptoms that can help in diagnosing the disorder. Which scale can be used
for assessment?

2. Discuss the etiological factors of Sarah’s disorder.

3. What treatment can be given to Sarah for the disorder?