Depression:

1
Depression

• What is it?

Alec Bodkin, M.D., Chief Clinical
Psychopharmacology Research Program McLean
Hospital, Belmont, MA
2
Depression is ancient

• Aretaeus of Capadocia (150-200 AD)
• The patients are dull or stern dejected or
  unreasonably torpid, without any manifest cause

3
Aretaeus

• They become peevish, dispirited, sleepless, and
  start up from a disturbed sleep. Unreasonable
  fears also seize them...

4
Aretaeus

• If the illness becomes more urgent, hatred,
  avoidance of the haunts of men, vain lamentations
  are seen. They complain of life and desire to
  die.

5
Depression is worldwide

• The World Health Organization has found that
  depression was the 4th leading cause of lost
  years of healthy functioning for humanity as of
  1990. (51 million)
• By 2020 it is predicted to be the 2nd leading
  cause of lost years of good health, after heart
  disease. (79 million)
• The Global Burden of Disease, 12 volumes, edited
  by Christopher J. Murray, et al, 1996-1997

6
Depression is physically as well as
psychologically impairing

• Impairment of physical and social functioning,
  and overall well-being, more severe for
  depression than 7 of 8 medical disorders in
  ambulatory care setting (Only chronic heart
  disease more disabling.)
• With all medical disorders, where depression was
  also present, impairment was additive.
• Wells et al, The functioning and well-being of
  depressed patients. JAMA, 1989

7
depressive illness is probably more unpleasant
than any disease except rabies.JS Price,
Chronic depressive illness, British Med J, 1978
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Silent epidemic

• Unlike many health problems, depression is hard
  for others to see
• The diagnosis has been shown to be missed by
  primary care physicians 50-80 of the time
• Depressed individuals may go undiagnosed for
  years, keeping their troubles to themselves

9
The daily experience
10
In 1990- 1992 in the US

• Depression was the most common psychiatric
  illness
• A Major Depressive Episode occurred sometime in
  life for 17.1 of the population
• Twice as frequent in women (21.3 vs 12.7)
• Only 20.9 of those with any psychiatric disorder
  in the last year got any professional help
• Kessler et al, Arch Gen Psych 1994

11
In 2000-2002 in the US

• 16.2 of the population had sometime experienced
  a Major Depressive Episode
• In the past year 6.6 had been depressed, causing
  an average of 35.2 missed days of work or school
• Role function was severely or very severely
  impaired for 59.3
• But only 21.7 received adequate treatment
• Kessler et al, JAMA 2003

12
The Diagnosis of Major Depression

• Low mood or loss of interest/pleasure in almost
  everything, for at least two weeks
• At least four additional symptoms Sleep changes,
  appetite changes, fatigue or low of energy,
  feelings of worthlessness or excessive guilt,
  poor concentration or indecisiveness, mental and
  physical slowing or agitation, suicidal thoughts
• Causes significant distress or impairment
• DSM-IV

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Common depressive symptoms

• Helplessness
• Brooding
• Passivity
• Pessimism
• Social Withdrawal
• Tearfulness

• Poor memory
• Neediness
• Irritability
• Bodily discomfort
• Hypochondria
• Loss of sexual interest

14
Subtypes of Depression

• MELANCHOLIC Anhedonia (near total loss of
  pleasure, incapacity to be cheered up) marked
  weight loss early morning awakening diurnal
  variation of mood, worse in the morning guilty
  rumination marked slowing or agitation.
• Onset often abrupt, from prior state of good
  psychological health. May be quite severe.

15
Subtypes of Depression

• ATYPICAL Reactive mood (Able to be cheered up
  by events). Overeating, oversleeping, and deep
  loss of energy (leaden paralysis) when depressed.
  Longstanding hypersensitivity to personal
  rejection.
• Onset more gradual, responsive to life events,
  course more chronic, usually less severe.

16
Subtypes of Depression

• PSYCHOTIC (or Delusional) rigid unjustified
  depressive beliefs, such as delusions of poverty,
  somatic delusions, delusional guilt, nihilism
• May occur in very severe depressive episodes
• More common in bipolar depression
• If delusions persist after depressive episode
  resolves, another illness is present

17
Subtypes of Depression

• DYSTHYMIC Less severely depressed mood and fewer
  secondary symptoms, but lasting longer a
  minimum of two years, often for decades
• May begin in childhood or adulthood
• As functionally impairing as major depression
• High risk of major depressive episodes (10/yr)
• (Double Depression)

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Subtypes of Depression

• BIPOLAR depression Earlier age of onset. Low
  energy, apathy, oversleeping, overeating, mental
  and physical slowing.
• Higher risk of psychosis
• Often the mirror image of the mania or hypomania
  which eventually appears

19
Subtypes of Depression

• SEASONAL DEPRESSION Episodes follow seasonal
  pattern
• Onset in Fall, recovery in Spring.
• Wintertime carbohydrate craving, oversleeping,
  low energy, social withdrawal.

20
Subtypes of Depression

• POSTPARTUM Occurs within one month of childbirth
• About 10 of childbearing women affected
• Distinct from brief baby blues
• Can be severe
• Increased risk with prior mood disorder

21
Depressive Subtypes under study

• Premenstrual Dysphoric Disorder
• Full major depressive syndrome the week before
  onset of every menses
• Minor Depressive Disorder
• 2-4 depressive symptoms, lasting at least a
  month
• Mixed Anxiety-Depressive Disorder
• Equal mix of depression and anxiety - may be
  very common in primary care
• Recurrent Brief Depressive Disorder
• gt2 day lt 2 week frequent major depressive
  spells, no mania, not premenstrual
• Depressive Personality Disorder
• Only psychological symptoms, consistently
  present since adolescence

22
Course of Depressive Illness

• Early episodes often follow major life stresses
  job loss, academic failure, major health
  problems, loss of close personal relationships,
  marital difficulties, childbirth
• Later episodes more likely to occur without major
  stressors.

23
Course of Depressive Illness

• Average age of first depression mid 20s (Has
  been getting earlier since 1940)
• Untreated episodes may last 4 months to 2 years
• 20 become chronic

24
Course of Depressive Illness

• Recovery from depressive episodes 50-60
  complete,
• 20-30 partial.
• Single episode is followed by a second episode
  over 50 of the time.
• Second episode is followed by a third episode 70
  of the time.
• Third episode is followed by a 4th 90 of the
  time. (maintenance treatment appropriate)

25
Familial Risk

• Major depression is 3 times more likely to occur
  in 1st degree relatives of depressed patients.
• Mixture of shared genes and shared environment
  account for this
• Depression is twice as likely to co-occur in
  identical twins as non-identical twins

26
Comorbidity

• Depression pure in only 1/4 cases
• Anxiety disorders found in over half of
  individuals with major depression
• Anxiety twice as prevalent in women correcting
  for preexisting anxiety, same rate of depression
  in men and women.
• Anxiety disorders generally predate onset of
  depression

27
Biology of Depression

• Depression resides in the brain, its not just in
  your mind
• The brain has measurable physical changes in
  depressed individuals (enlarged amygdala, right
  cerebral hemisphere more active, hypocampus may
  be shrunken)
• Increasing available brain serotonin and
  norepinephrine heals depression

28
Biology of Depression

• Abnormalities of brain chemistry underlie
  depressive episodes
• There is a genetic vulnerability to these
  abnormalities of brain chemistry
• Life stresses can precipitate depressive episodes
  in biologically vulnerable individuals. A
  vulnerability gene may have been found (the
  5-HTT gene).

29
Genetic Vulnerability

• 850 New Zealanders were questioned about
  stressful life events.
• They were tested for a long or short serotonin
  transporter gene
• Of people faced with 4 or more stressful events
  in the past 5 years 33 with the short gene got
  depressed, but only 17 with the long gene
• Caspi et al, Influence of life stress on
  depression. Science 2003

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Summary

• Depression is an illness - not a character flaw
• Depressive illness impairs the whole person,
  physically and mentally - sometimes unbearably
• Depressive illness is usually highly treatable
• The diagnosis is still often missed
• Untreated, Depression can be devastating

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Summary

• Though the vulnerability to depression runs in
  families, so can Depression Awareness
• Awareness allows early identification of
  depressive symptoms, and getting appropriate help
  
• Awareness enhances coping with harmful life
  stressors before illness ensues
• Awareness will speed recovery, and reduce the
  burden of depression