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The following lecture has been approved for
University Undergraduate Students This lecture
may contain information, ideas, concepts and
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insight, reflection or critical evaluation
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Depressive Illness Dr. Craig Jackson Senior
Lecturer in Health Psychology Faculty of Health
BCU health.bcu.ac.uk/craigjackson
craig.jackson_at_bcu.ac.uk
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The good physician treats the disease, but
the great physician treats the person.
William Osler
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Traditional model of Disease Development
Pathogen
Disease (pathology)
Modifiers Lifestyle Individual susceptibility
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Dominance of the biopsychosocial
model Mainstream in last 15 years
Hazard
Illness (well-being)
Psychosocial Factors Attitudes Behaviour Quality
of Life
Rise of the person as a psychological entity
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Depressive Illness Usually treatable Common Mar
ked disability Reduced survival Increased
costs Depression may be Coincidental
association Complication of physical illness
(i.e. secondary depression) Cause of /
Exacerbation of somatic symptoms
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Psychiatry in Pictures Steve Blundell
Digital Cry Stapled Red
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Depressive Illness 2 of population suffer from
pure depression (evenly distributed between mild,
moderate, and severe) Further 8 suffer from a
mixture of anxiety and depression Patients with
symptoms not severe enough to qualify for
diagnosis of either anxiety or depression.....
??? Impaired working and social lives and many
unexplained physical symptoms Greater use of
medical services Walking Well
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• Spectrum of mood disturbance
• Mild thru to Severe
• Transience thru to Persistence
• Continuous distribution in population
• Clinically significant when
• (1) interferes with normal activities
• (2) persists for min. 2 weeks
• Diagnosis of depression / depressive disorder
• Persistent pervasive low mood
• Loss of interest or pleasure in activities
• Ennui

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• Epidemiology
• 2nd biggest cause of disability
• worldwide by 2020 (WHO)
• (IHD still the biggest)
• Associated with increased
• physical illness
• 5 during lifetime have MDD
• 1 in 20 consultations
• 100 patients per GP
• MDD Dysthmia gt in females
• 20 develop chronic depression
• 30 of in-patients have depressive symptoms

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Suicide
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• Suicide
• Final clinical pathway
• 1 million deaths per year, 10-12 million attempts
• UK Males most common in older
• Female most common in middle age
• Steady decline since 1990
• 5,554 suicide deaths in UK 2006
• 15 per 100,000 deaths males
• 6 per 100,000 deaths females

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• Almost 50 fail on first attempt
• Previous attempters 23 times more likely to dies
  from suicide than those without previous attempts
• Internal stress
• Pre-existing psychiatric morbidity Stack 2001
• Demographics
• Opportunities

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Behavioural Indicators - recent bereavement or
other life-altering loss - recent break-up of a
close relationship - major disappointment
(failed exams or missed job promotion) - change
in circumstances (retire, redundant or children
leaving home) - physical illness - mental
illness - substance misuse / addiction -
deliberate self-harm, (particularly in women) -
previous suicide attempts - loss of close friend
/ relative by suicidal means - loss of status -
feelings of hopelessness, powerlessness and
worthlessness - declining performance in work /
activities (sometimes this can be reversed) -
declining interest in friends, sex, or previous
activities - neglect of personal welfare and
hygiene - alterations in sleeping habits (either
direction) or eating habits
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• Case Summary of a Depressed Patient 1
• Date Symptoms Referral
• 1985 (16) Anorexia Secure unit teenagers
• 1986 (17) Suicide attempt Secure unit teenagers
• 1986 (17) Self-harm Secure unit CAMHS
• (A levels) Psychiatry - ECT unsubstantiated
• 1987-9 Self-harm. Anorexia UMC
• (18-20) (university)
• 1990 Working as au pair GP monitoring
  anti-depressants
• (21) (left university)
• 1993 Self-harm Secure unit admission
• (24) (joined commune)

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• Epidemiology
• Depression more common in those with
• Life threatened / limited / chronic physical
  illness
• Unpleasant / demanding treatment
• Low social support
• Adverse social circumstances
• Personal / family history of depression /
  psychological vulnerability
• Substance misuse
• Anti-hypertensive / Corticosteroid /
  Chemotherapy use

Q o L
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Aetiology Most depressions have triggering life
events - Reactive depression Especially in a
first episode Many patients present initially
with physical symptoms (somatization) Some may
show multiple symptoms of depression in the
apparent absence of low mood - Masked
Depression Some depression has no triggering
cause - Endogenous Depression More persistent
and resistant to treatment
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• Clinical Features
• Adjustment Disorders
• mild
• short-lived
• reactive episodes
• Major Depressive Disorder (MDD)
• 5 symptoms displayed in 14 days
• Dysthymia
• depressed mood for 2 years
• not severe
• chronic depression
• unhealthy lifestyle associations
• Bipolar Disorder / manic depression
• major depression mania

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• Major depression (DSM IV)
• 5 or more..
• decreased interest / pleasure
• depressed mood
• reduced energy
• weight gain / loss
• insomnia / hypersomnia
• feeling worthless
• guilt
• recurrent morbid thought
• psychomotor changes
• fatigue
• poor concentration
• pessimism / bleak views
• self harm ideas / actions
• suicide ideation

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• Classification of Depression (ICD-10)
• PrimaryUnipolar
• Mixed anxiety and depressive disorder (prominent
  anxiety)
• Depressive episode (single episode)
• Recurrent depressive disorder (recurrent
  episodes)
• Dysthymia - Persistent and mild ("depressive
  personality")
• Bipolar
• Bipolar affective disorder - manic episodes
  ("manic depression")
• Cyclothymia - Persistent instability of mood
• Other primary
• Seasonal affective disorder
• Brief recurrent depression
• Depressive episode may be
• Moderate or severe
• With/Without somatic syndrome
• With/Without psychotic symptoms

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• Somatization Syndrome (DSM IV)
• 4 or more..
• Anhedonia
• Loss of emotional reactivity
• Early waking (gt2 hours early)
• Psychomotor retardation or agitation
• Marked loss of appetite
• Weight loss gt5 of body mass in one month
• Loss of libido

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Linking Emotions with Physical Symptoms
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Case Summary of a Depressed Patient
2 Date Symptoms Referral 1985
(17) Pervasive low mood GP monitors 1986
(18) Suicide attempt Child Psychiatry 1986
(18) Self-harm Psychiatry 1987 (19) Anorexia.
Self-harm Psychiatry CPN 1988 (20) Suicide
attempt Psychiatry CPN (failed romance) 1989
(21) Suicide attempt Psychiatry CPN (failed
romance) 1990 (22) Fertility worries Psychiatry
CPN fertility counselling 1990 (22)
Working in office GP monitoring
anti-depressants 1992 (24) Self-harm MH unit
(open door policy) CPN 1996 (26) Chronic
Fatigue MH unit (open door policy) CPN 1998 (28)
Fibromyalgia MH unit (open door policy) CPN
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Risk Factors Existing Health Conditions
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Depressed Patients and Positive
Symptoms Rosemary Carson Sensations of
maggots moving within her body Depressed,
attempted suicide at the age of 15 Spent long
periods of early adult life in psychiatric
hospitals Treated with medication and electro
convulsive therapy 17-year remission in
affective symptoms and sensations of maggots By
1996 became ill again - began to hear voices Her
art captures memories of fellow patients and
situations from earlier admissions
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Depressed Patients and Positive
Symptoms Rosemary Carson -
The Hospital Ward at Night
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• Classification
• Many patients do not fit neatly into categories
  of either anxiety or depression
• Mixed anxiety and depression is now recognised
• Presence of physical symptoms indicates a
  somatic syndrome
• Value of somatic features in predicting response
  to treatment is not clear
• Presence of psychotic features has major
  implications for treatment
• Brief episodes of more severe depression are
  also recognised
• (brief recurrent depression)
• More prolonged recurrence is now termed
  recurrent depressive disorder

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• Return to Work
• Longer off work Less likely to return to work

Waddell, 1994
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• Risk Factors
• Anxiety Sadness Somatic discomfort
• Normal psychological response to life stress
• Clinical depression is a final common pathway
• Resulting from interaction of biological,
  psychological, and social factors
• Likelihood of this outcome depends on many
  factors
• genetic and family predisposition
• clinical course of concurrent medical illness
• nature of any treatment
• functional disability
• individual coping style
• social and other support

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Risk Factors - Causality Certain illnesses such
(stroke, Parkinson's disease, multiple sclerosis,
and pancreatic cancer) may cause depression via
direct bio mechanisms. Stroke received most
attention, but studies fail to show convincing
direct aetiology
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• Psychological Consequences of Chronic Illness
• e.g. Cancer
• Distress
• Reduced QoL
• Delay seeking help Fear Denial
• Depressed / Anxious
• Increased somatic complaints (Pain Fatigue Breath
  lessness)
• Adjustment Disorder commonest psychiatric
  diagnosis
• Neuropsychiatric complications
• Increased risk of suicide in early stages

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• Depression in Cancer Patients
• Response to perceived loss
• Awareness of losses to come bereavement
• Loss of body, family, friends, role, life
• Severe depression X4 likely in cancer patients
• 10-20 of cancer patients

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Behavioural Responses to Diagnoses Hedonism Put
life in order Premature grieving Sick
Role Illness Behaviour Over-sensitivity to
symptoms Premature death
ADAPTIVE COPING Talk about it Planning Changes M
ALADAPTIVE COPING Drink Eat Substance use
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• Neuropsychiatric Complications
• Brain metastases
• Delirium
• Dementia
• Depression
• Produce psych. symptoms before discovery
• Paraneoplastic Syndromes
• Neuropsychiatric problems in absence of
  metastases
• Orig. lung, ovary, breast, stomach, or Hodgkins

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• Neuropsychiatric syndromes
• 61 yr old female
• Frontal headaches for 3 months
• Lethargic and weak
• Difficulty walking
• Diffuse areas of nodular destructive
• lesions
• Consistent with multiple myeloma or
• metastatic disease

• Skeleton is common site for mets from carcinomas
  and occasionally sarcomas
• Lesions may be silent or symptomatic, such as
  pain, swelling, deformity,
• compression of the spinal cord, nerve roots, or
  pathologic fractures.

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• Recognition Diagnosis
• Often missed in diagnoses
• Distinguish depressed behaviour (sadness and loss
  of interest), from realistic expected response
  to stress / physical illness
• Confusion of whether physical symptoms of
  depression are due to underlying medical
  condition
• Negative attitudes to diagnosis of depression
• Unsuitability of clinical setting for discussing
  personal emotional matters
• Patients' unwilling to report symptoms of
  depression

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• Recognition Diagnosis
• Depressive illness is often under-diagnosed and
  under-treated
• Especially if it coexists with physical illness
• This often causes great distress for patients
  mistakenly assumed
• that symptoms (weakness or fatigue) are due to an
  underlying medical
• condition.
• Practitioners must be able to diagnose and manage
  depressive illness
• Alertness to clues in interviews
• Patients' manner
• Use of screening questions can detect up to 95
  of patients with major
• depression.

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Screening Questionnaires How have you been
feeling recently? Have you been low in
spirits? Have you been able to enjoy the
things you usually enjoy? Have you had your
usual level of energy, or have you been feeling
tired? How has your sleep been? Have you been
able to concentrate on your favourite tv
shows? Self-report screening instruments Beck
Depression Inventory (BDI) General Health
Questionnaire (GHQ) Hospital Anxiety Depression
Scale (HAD) Cant replace systematic clinical
assessment LISTENING Persistent low mood and
lack of interest and pleasure in life cannot be
accounted for by severe physical illness alone
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Non-Specific Symptoms Often missed in assessment
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Prevalence of Non-Specific Symptoms
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Drug Treatment Tricyclics since the 1950s
effective and cheap limit compliance variable
degrees of sedation fatal in overdose (except
Lofepramine) dose-related anticholinergic side
effects postural hypotension Monoamine Oxidise
Inhibitors (MAOIs) rare fatalities tyramine-free
diet Selective Serotonin Re-uptake Inhibitors
(SSRIs) fluoxetine lack sedation no
anticholinergic effects improved compliance less
immediate benefit for disturbed sleep safe in
overdose single or narrow range of doses works
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Placebo Nocebo In approx. 30 of
pop. Subjected to more clinical trials than any
other medicament Nearly always does better than
anticipated The range of susceptible conditions
seems limitless Does not always occur Present in
subjective and objective outcomes Negative
outcomes can occur (Nocebo effect) Placebo Big
pills better than smaller pills Red pills better
than blue 4 pills better than 2 30 of pop.
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Long Term Prognosis
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Identifying Unhelpful Patient Beliefs Discuss
potential unhelpful beliefs Counter any simple
aetiological beliefs Outline biopsychosocial
perspective Can highlight potential perpetual
factors that inhibit recovery Agree on positive
open minded approach Do not argue over best
name for condition!
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• Treatment
• Much depressive illness of all types is
  successfully treated in primary care
• Four main reasons for referral to specialist
  psychiatric services
• 1) Condition is severe
• 2) Failing to respond to treatment (e.g.
  Psychomotor retardation)
• 3) Complicated by other factors (e.g.
  Personality disorder)
• 4) Presents particular risks (e.g. Agitation and
  psychotic behaviour)
• Principal decision is whether to treat with
  drugs or a talking therapy
• Most patients in primary care settings would
  prefer a talking therapy
• Effectiveness is limited to particular forms of
  psychotherapy
• Mild-Mod. Depression CBT and antidepressants
  are equally effective
• Severe Depression antidepressant drugs are more
  effective

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• Management
• The main aims of treatment
• improve mood and quality of life
• reduce the risk of medical complications
• improve compliance with and outcome of physical
  treatment
• facilitate the "appropriate" use of healthcare
  resources
• Primary care staff should be familiar with
  properties and use of
• 1) common antidepressant drugs brief
  psychological treatments
• 2) assessment of suicidal thinking and risk
• Patients with more enduring or severe symptoms
  will usually require specific treatment - usually
  drug therapy
• For patients with suicidal ideation / whose
  depression has not responded to initial
  management, specialist referral is the next step

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Management Low level risk Clinical
picture Action     Suicidal ideation
Consider referral to mental health but no
suicide attempts professional for routine
appointment (not always necessary) Supportiv
e environment Physically healthy No history of
psychiatric illness
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Management Moderate level risk Clinical
picture Action     Low lethality suicide
attempt Refer to mental health
professional (patient's perception of lethality)
to be seen as soon as possible Frequent
thoughts of suicide Previous suicide
attempts Persistent depressive symptoms Serious
medical illness Inadequate social support History
of psychiatric illness
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Management High level risk Clinical
picture Action     Definite plan for suicide
Refer to mental health professional (When?
Where? How?) for immediate assessment Major
depressive disorder High lethality suicide
attempt or multiple attempts Advanced medical
disease Social isolation History of psychiatric
illness
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• Summary
• Detection can be hard symptom overlap and
  patient unaware
• Depression a natural occurrence in population
• Whole range of depressive conditions with
  varying severity
• Depression can be present in acute or chronic
  states
• Depression can have physiological, biological or
  social causes
• Depression may have a mixture of causes
• Depression co-exists with many other symptoms
• Depression is a natural reaction to disease
  diagnosis and presence
• Depression and symptomotology are highly related