Depression

Depression

Dr. Safeya Alchalabi

Atypical depression

Mild depressive states

Minor anxiety–depressive disorders (‘mixed anxiety and depressive disorder’)(Minor affective disorder) or (‘Unspecified Depressive Disorder’)

Transcultural factors

Melancholic depression(Major depression with melancholia in DSM-5, or depressive episode with somatic symptoms in ICD-10).
• melancholic depression is associated with the following clinical correlates:
● more severe symptomatology
● family history of depression
● poor response to placebo medication
● possibly better response to tricyclic antidepressants than selective serotonin reuptake inhibitors (SSRIs)
● more evidence of neurobiological abnormalities (e.g. decreased latency to rapid eye movement sleep, cortisol hypersecretion).


Melancholic depression(Major depression with melancholia in DSM-5, or depressive episode with somatic symptoms in ICD-10).
• Clinical features of depression with ‘somatic’ or ‘melancholic’ features:
● Loss of interest or pleasure in usual activities
● Lack of emotional reactivity to normally pleasurable surroundings and events
● Early-morning waking (2 hours or more before usual time)
● Depression worse in the morning
● Psychomotor agitation or retardation
● Marked loss of appetite
● Weight loss (5% or more of body weight in last month)
● Marked loss of libido
● Distinct quality of depressed mood
● Excessive guilt

Non-melancholic depression

(mild depressive episodes and atypical depression) or (‘neurotic depression’).
These depressions are more likely to have a relative prominence of features, such as anxiety, hostility, phobias, and obsessional symptoms.

Seasonal affective disorder

• These symptoms include:
● hypersomnia
● increased appetite, with craving for carbohydrate
● an afternoon slump in energy levels.
The most common pattern is onset in autumn or winter, and recovery in spring or summer.
This condition is also called ‘winter depression’.
Some patients show evidence of hypomania or mania in the summer, which suggests that they have a seasonal bipolar illness.
This pattern has led to the suggestion that shortening of daylight hours is important in the pathophysiology of winter depression.
treatment methods include exposure to bright artificial light during hours of darkness.


Recurrent brief depression
recurrent depressive episodes of short duration, typically 2–7 days,
These episodes recur with some frequency, about once a month on average.
Although the depressive episodes are short, they are as severe as the more enduring depressive disorders, and can be associated with suicidal behaviour.
Thus recurrent brief depression is associated with much personal distress and social and occupational impairment.
treatment with antidepressant medication, but its value is questionable.

The epidemiology of depressive disorders

Major depression
● The 12-month prevalence of major depression in the community is around 2–5%.
● The lifetime rates probably lies in the range 10–20%.
● The mean age of onset is about 27 years.
● Rates of major depression are about twice as high in women as in men.
● Rates of depression are higher in the unemployed and divorced.
● Major depression has a high comorbidity with other disorders, particularly anxiety disorders and substance misuse.
● major depression is most prevalent in the 18–44-year age group.

The epidemiology of depressive disorders

Dysthymia and recurrent brief depression
The lifetime risk for dysthymia is around 4%.
Rates of dysthymia are higher in women and in the divorced.
the 12-month prevalence for recurrent brief depression was about 2.6%, very similar to the rate found for dysthmia (2.3%) .


The epidemiology of depressive disorders
Minor anxiety–depressive disorders
these are probably the most prevalent psychiatric disorders in the community ( 1-week prevalence of 9%).

Course and prognosis of depression

Major depression
10%  manic illness.
50%  before the age of 21.
length of a depressive episode6 months
25% episodes last more than 1 year
10–20%  chronic course.
80% recurrent major depression.
50%  no complete remission (subsyndromal ).
25% of recurrent depression achieve a period of 5 years of clinical stability with good social and occupational performance.

Course and prognosis of depression

Dysthymia
50% of outpatients a clinical recovery over a 5-year follow-up.
some dysthymiaMDD(double depression)
some major depression subside into dysthymia.
The development of mania is rare.


Course and prognosis of depression
Minor depressive disorders
recurrence rate similar to that of major depression
minor depression is likely to be a risk factor for major depression, and may also be a residual state following remission of major depression.

Course and prognosis of depression

major and minor depression and dysthymia are not distinct conditions, but represent part of a spectrum of depressive disorders.

Mortality of depressive disorders

Twice
excess deaths are due to  suicide, accidents, cardiovascular disease, and comorbid substance misuse.
increase the risk of general medical conditions such as diabetes and cardiovascular disease.
treatment lowers the mortality
Rates of suicide 15 times higher than those in the general
Risk of suicide  may be as high as 15%.
risk of suicide is highest during the early stages of the illness later mortality from natural causes becomes more significant

Prognostic factors

• ● incomplete symptomatic remission
• ● early age of onset
• ● poor social support
• ● poor physical health
• ● comorbid substance misuse
• ● comorbid personality disorder.


The acute treatment of depression
Antidepressant drugs
Short-term response rates are about 50%
There is little to choose between the various antidepressants

The acute treatment of depression

Tricyclic antidepressants
TCAs are not differ from one another in clinical efficacy.
Lofepramine is relatively safe in overdose.
Tricyclics are probably not effective treatments for adolescents with depression.

The acute treatment of depression

Selective serotonin reuptake inhibitors and serotonin and noradrenaline reuptake inhibitors
they are as effective as tricyclic antidepressants.
Venlafaxine (SNRI), appears to be slightly more effective than SSRIs in patients with more severe depressive states.
SSRIs are more effective than tricyclic antidepressants (with the exception of clomipramine) where depression occurs in association with obsessive–compulsive disorder.
Duloxetine is another SNRI, does not more effective than SSRIs.
escitalopram and sertraline are the most effective of the SSRIs.

The acute treatment of depression

Tolerance of SSRIs relative to tricyclics
SSRIs are associated with lower dropout rates due to side effects,
SSRIs relatively safe in overdose; however, venlafaxine is less safe in overdose than SSRIs.


The acute treatment of depression
Monoamine oxidase inhibitors
MAOIs are of equal therapeutic activity to tricyclic antidepressants for moderate to severe depressive disorders.
MAOIs are liable to cause dangerous reactions with other drugs and some foods.
MAOIs can be effective in depressed patients who have not responded to tricyclic antidepressants and SSRIs.
The reversible type-A MAOI moclobemide has the advantage of not requiring adherence to a low-tyramine diet.

The acute treatment of depression

• Clinical characteristics of some antidepressant drugs

•

• Anticholinergic
• Sedation
• Weight gain
• Sexual dysfunction
• Toxicity in overdose
• Amitriptyline
• +++
• +++
• +++
• +
• +++
• Lofepramine
• +
• 0
• 0
• +
• 0
• SSRIs
• 0
• 0
• +
• +++
• 0*
• Venlafaxine
• 0
• 0
• +
• +++
• ++
• Duloxetine
• 0
• 0
• +
• +++
• ?
• Trazodone
• 0
• +++
• +
• 0
• +
• Reboxetine
• +
• 0
• 0
• +
• 0
• Mirtazapine
• 0
• +++
• +++
• 0
• 0
• Agomelatine
• 0
• +
• 0
• 0
• ?


The acute treatment of depression
Lithium in combination with antidepressants
lithium can produce useful therapeutic effects when added to antidepressant medication in treatment-resistant patients (lithium augmentation).
40% of depressed patients responded to lithium augmentation of their antidepressant regimen.
The more usual pattern of response is a gradual resolution of symptoms over 2–3 weeks.

The acute treatment of depression

Anticonvulsants
Anticonvulsants such as carbamazepine, valproate, and lamotrigine are useful in the management of bipolar disorder, and in these circumstances can prevent episodes of major depression.
Lamotrigine has been shown to have antidepressant effects.

The acute treatment of depression

Atypical antipsychotic drugs
Antipsychotic drugs are often combined with antidepressant drugs in the treatment of patients with depressive psychosis
atypical antipsychotic agents (aripiprazole, quetiapine, risperidone, and olanzapine), used at relatively low dose, can be of benefit when combined with antidepressants in non-psychotically depressed patients who have failed to respond to antidepressant treatment alone (e.g. ineffective SSRI treatment).

The acute treatment of depression

Electroconvulsive therapy
Indications for ECT
severe depressive disorders (marked weight loss, early-morning waking, retardation, and delusions).
depressive psychosis respond better to ECT than to tricyclic antidepressants or antipsychotic drugs given alone (combined treatment with antidepressants and antipsychotic drugs may be about as effective as ECT).
depressed patients who have not responded to full trials of medication (in such patients relapse rates are high).


The acute treatment of depression
Psychological treatment
• ● supportive psychotherapy
• ● cognitive behaviour therapy
• ● interpersonal psychotherapy
• ● behavioural activation
• ● marital therapy
• ● dynamic psychotherapy.

The acute treatment of depression

Supportive psychotherapy and problem-solving
focusing on the identification and resolution of current life difficulties
using the patient’s strengths and available coping resources.

The acute treatment of depression

Cognitive behaviour therapy
The essential aim of cognitive behaviour therapy is to help the patient to modify their ways of thinking and acting in relation to life situations and depressive symptoms.

The acute treatment of depression

Behavioural activation
Behavioural activation uses the principles of operant conditioning by tracking the links between actions and emotional outcomes.
The goal of therapy is to assist patients, to engage in behaviours that will lead to a positive effect on mood.


The acute treatment of depression
Interpersonal psychotherapy
Interpersonal therapy is a systematic and standardized treatment approach to personal relationships and life problems.

The acute treatment of depression

Couple therapy
Couple therapy can be offered to depressed patients for whom interactions with a partner appear to have contributed to causing or maintaining the depressive disorder.

The acute treatment of depression

Dynamic psychotherapy
It aims to resolve underlying developmental conflicts and attendant life difficulties that are believed to be causing or maintaining the depressive disorder.

The acute treatment of depression

Sleep deprivation
rapid short-term changes in mood can be brought about by keeping patients awake overnight.
There are reports that sleep deprivation can be used to hasten the onset of effect of antidepressant drugs, and also that some pharmacological manipulations can prolong the effect of sleep deprivation.

The acute treatment of depression

Bright light treatment
Over 50% of patients with recurrent winter depression respond to bright light treatment.
Treatment is usually given for an hour or two in the morning.
The duration of exposure usually needs to be 1–2 hours.
Dim light is less effective than bright light.
The usual onset of the antidepressant effect of bright light is within 2–5 days.
Patients with ‘atypical’ depressive features such as overeating and oversleeping appear to respond best.
To avoid relapse, light treatment usually needs to be maintained until the usual time of natural remission, in the early spring.
Bright light treatment may also be effective in non-seasonal depression—for example, in elderly people with depression, where circadian rhythm disturbances may be involved in pathophysiology.
morning light treatment may augment the therapeutic effect of antidepressant medication in non-seasonal depression


The acute treatment of depression
Couple therapy
Couple therapy can be offered to depressed patients for whom interactions with a partner appear to have contributed to causing or maintaining the depressive disorder.

The longer-term treatment of depression

Prevention of relapse and recurrence
Relapse refers to the worsening of symptoms after an initial improvement during the treatment of a single episode of mood disorder.
Recurrence refers to a new episode after a period of complete recovery.
Treatment to prevent relapsecontinuation treatment.
Treatment to prevent recurrence  prophylactic or maintenance treatment.

Drug treatment of unipolar depression

Stopping antidepressants soon after a treatment response a high risk of relapse.
one-third next year (first 6 months).

The role of continuation therapy have reached the following conclusions:

● continuing antidepressant treatment for 6 months halves the relapse rate.
● Treatment should be effective dose
● low risk of further episodes, continuation for longer than 6 months  little extra benefit (except in the elderlycontinuation therapy for 12 months is more appropriate).

Drug treatment of unipolar depression

*Recurrent depression  (defined as at least three episodes over the past 5 years).

The assessment of depressive disorders

● To decide whether the diagnosis is depressive disorder.
● To judge the severity of the disorder, including the risk of suicide.
● To form an opinion about the causes.
● To assess the patient’s social resources.
● To gauge the effect of the disorder on other people.

(‘Masked depression’).

Depressive symptoms, could be part of another disorder
Certain drugs—both legal and illegal—can induce depression.

The assessment of depressive disorders

The management of depressive disorders
What patients and families want to know Particularly for patients with a first episode of moderate to severe depression,:
1. What is wrong with me?
2. Can I recover?
3. What treatment do I need?
4. What can I do to improve the situation?
5. Can my family be helped?