1. Understanding
Depression
Madan Baral
Second Semester, B. Pharmacy
School of Health and Allied Sciences
Pokhara University, Dhungepatan,
Lekhnath-12, Kaski , Nepal

2. Objectives
•Understand Signs and Symptoms
•Differentiate between types of depression
•Understand Causation
•Understand Diagnosis Methods
•Understand Treatment

3. WHAT IS DEPRESSION ?
•common potentially debilitating
psychiatric disorder characterized
by depressed mood, loss of
interest or pleasure, feelings of
guilt, disturbed sleep or appetite,
low and poor concentration.

4. HISTORY
•Ancient Egyptians wrote about depression more than 3000
years ago
•Ancient Greek thought depression as the cause of excess of
bile
•Hippocrates, first person to throughly describe the condition
as a somatic illness and coin the term “melancholia”
•Ludwig Van Beethoven, Charles Dickens, Winston Churchill,
Abraham Lincoln and Ernest Hemingway some famous
people said to have suffered from depression

5. CLASSIFICATION ON THE BASIS DSM-IV
• Depression classified with its subtypes under Mood Disorder by American
Psychiatric Association published in Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV)
✦ Mood Disorder
A. Depressive Disorder
1. Major Depressive Disorder, Single Episode
2. Major Depressive Disorder, Recurrent
3. Dysthymia Disorder
4. Depressive Disorder Not Otherwise Mentioned
– Bipolar Disorder
» Bipolar Disorder, Single Episode
» Bipolar Disorder, Recurrent
A.Cyclothymic Disorder
1. Bipolar Disorder Not Otherwise Specified
1. Secondary Mood Disorder due to Non-psychiatric Medical Condition
2. Substance- Induced Mood Disorder
3.Mood Disorder Not Otherwise Specified

6. Facts and Statistics
•People of all ages, backgrounds, lifestyles, and nationalities
suffer from major depression, with a few exceptions.
•Up to 20% of people experience symptoms of depression.
•The average age of first onset of major depression is 25-29
•Ranked as 4th
highest public concern according to WHO and
assumed to be 2nd by 2020

7. Major Depressive Disorder
•Also called clinical depression or unipolar depression
•The most prevalent depressive disorder
•Some 340 million persons worldwide meet the criteria for
clinical depression

8. Symptoms
•The symptoms of depression are:
Emotional Symptoms: Physical Symptoms:
Depressed mood Change in body weight and appetite
Loss of interest or pleasure Disturbances of sleep and other
Circadian rhythm
Anxiety Fatigue
Diminished ability to think or
concentrate, or indecisiveness
Psychomotor agitation or
retardation
Feeling of excessive or
inappropriate guilt
Unexplained body aches
Recurrent thoughts of deaths and
suicidal
Headache

9. Types
•Classified further on the basis of occurrence
a. Single Episode
b. Recurrent
•Single episode - occurs only once and meets all the diagnostic
symptoms of major depression
•If untreated, 85% of persons who have one episode of
depression will have another episode within 10 years
•Recurrent-2 major depression episodes, separated by at least a
2 month period
•Median number of depressive episodes per person is 4
•25% have 6 or more episodes

10. Dysthymia
• chronic “low-grade” or mild depression
• symptoms not as strong as the symptoms of major depression
• Diagnostic Symptoms :
A. Depressed/irritable mood
B. Presence of two of the following:
• Appetite disturbance
• Sleep disturbance
• Low energy/fatigue
• Poor concentration of difficulties making decision
• Feelings of hopelessness
C. Present for two year period (one year in children and adolescents)

11. Bipolar Disorder
•manic-depressive disorder
•presence of one or more episodes of abnormally elevated
energy levels, cognition, and mood with or without one or
more depressive episodes
Characteristic Episodes
– Depressive Episode :disturbances in sleep and appetite,
fatigue,
–Manic Episode : elevated, irritable mood state ,grandiosity
–Hypomanic Episode : milder mania

12. Etiology and Pathophysiology
A.Biological Theories
1.Genetics
2.Biochemical Theories
a. Monoamine Hypothesis
b. Neurotransmitter Dysregulation Hypothesis
c. Neuroendocrine Findings
B.Psychological Theories
1. Psychoanalytical Factors
A. Learning Theories
1. Object Loss theory
2. Cognitive Theory
a. Social Theory
a.Family Based
c.Society Based

13. Genetics
Family Studies
• first degree relatives of (children,siblings,parents) of
depressed individuals are 1.5 to 3 times more likely to have
depression compared to general population
Twin Studies
•concordance rate of monozygotic twins ranges from 54-65%
while in dizygotic twins in only 15-24

14. Biochemical Theories
• Monoamine Hypothesis
• Neurotransmitter Dysregulation Hypothesis
• Neuroendocrine Findings

15. Monoamine Hypothesis
• Depletion in the levels of serotonin, norepinephrine, and/or
dopamine in the CNS.
• Norepinephrine regarded as the component in the mobilization of
the body toy deal with stressful event.
• Serotonin System- mood and arousal thinking,energy, libido,
cognition,appetite,aggression and circadian rhythm.
• Dopamine System -human mood and behavior.
• Decreased level of biogenic amines in synaptic cleft inhibits the
transmission of impulses from one neuron to another causing a
failure of the cells to fire or charge.
• Pathophysiology supported by the mechanism of action of
antidepressants and autopsy of depressed person

18. Monoamine Hypothesis
Limitations
• Delayed onset of drug
• Not all the depressed patient have decreased synaptic
concentration of of biogenic amines
• antidepressant can work via other mechanisms which do not
involve reactive increased in synaptic neuro-transmitter
concentration (eg. can block corticotropin releasing factor)

19. Neurotransmitter Dysregulation Hypothesis
•Explains depression as the cause of failure of regulation of
neurotransmission system
Factors
- Impairment in homeostasis or regulation
- Disruption of normal periodicity ( Circadian rhythm )
- less selective response to stimuli

20. Neuroendocrine Findings
•Neuroendocrine abnormalities may develop depression
•Abnormal thyroid function test including low
triiodothronine(T3) and thyroxine(T4)
•Abnormal response to TRH(thyroid releasing hormone)
consisting or blunted or exaggerated thyroid stimulating
hormone (TSH)
•Clinical hypoparathyroidism
•HPA axis influence manifestation of depression
•Concentrations of CRF is elevated during depressive episodes
•Decreased hippocampus

22. Psychological Theories
• Psychoanalytical Theory
• Learning Theories
• Object Loss theory
• Cognitive Theory

23. Psychoanalytical Theory
•Sigmund Freud features of melancholia
– a profoundly painful dejection
– loss of interest in world
– loss of capacity to love
•Interpretation of melancholia
– actual loss of loved one or emotional rejection
–feelings of self-hatred develop and worthlessness and losses
his or her self-esteem

24. Learning Theory
•Seligman’s “learned helplessness” experiment on dogs
•Helplessness in human with numerous traumatic situations
either real or perceived
•Seligman’s interpretation of depression
–Learned helplessness predisposes depression by imposing a
feeling of lack of control and hopelessness over their life
situation and failures

25. Object Loss Theory (Attachment Theory)
•Attachment theory by John Bowlby, English psychiatrist,
•Relationship between depressive disorder in adulthood and
the quality of the earlier bond between the infant and their
adult caregiver.
•The experiences of early loss, separation and rejection by the
parent or caregiver
•Absence of security and emotional absence

26. Cognitive Theory
• Put-forth by Aaron Beck
•3 cognitive distortion reality
•Negative expectation
– Environment
– Self
– Future
•Contrary view

27. Social Theory
•Family
–Problems with family
–Family stress
•Social
–Substantial life events
–Social isolation

28. Diagnosis
•Clinical Assessment
•Behavioral Rating Scales
•DSM-IV Criteria and IDS-10 Criteria

29. Clinical Assessment
•By Clinician,trained medical practitioner, psychiatrist or
psychologist
•Mental state assessment
– appearance, behavior speech, mood, memory, and
intellectual function
•Physical Examination
– palpitation in neck, laboratory tests ( TSH, thyroxine,
testosterone level)
•Other bodily changes

30. Behavioral Rating Scales
•Set of questionnaire for depression assessment
•Uses
– Screening mental state
– Quantifying target symptoms
– Determine treatment efficacy
•Clinically preferred
– Hamilton Rating Scales for Depression (HRS-D)
– Montgomery-Asberg Rating Depression Rating Scale
–National Institute of Mental Health Diagnostic Interview
Schedule (DIS)

31. DSM-IV Criteria and ICD-10 Criteria
•DSM-IV
– American Psychiatric Association's revised fourth edition
of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR)
•ICD-10
– World Health Organization's
International Statistical Classification of Diseases and Related Health
(ICD-10)

32. Treatment
•Non-Drug Therapy
–Psychotherapy
–Phototherapy
–Electroconvulsive Therapy
•Pharmacotherapy

33. Psychotherapy
•Interpersonal therapy:
–assist in solving relationship
problems that cause depression
•Cognitive-behavioral therapy:
– changes the pessimistic ideas
and unrealistic expectations
–develop positive life goals, and a
more positive self-assessment

34. Electroconvulsive Therapy
How is it done?
•Pulses of electricity are sent through the
brain via two electrodes
•Painless procedure
•A person is put to sleep with general
anesthesia
•Muscle relaxers are used to prevent any
injury from the procedure
Advantages
•Quicker effect than antidepressant therapy
and thus may be the treatment of choice in
several emergency occasions

35. Pharmacotherapy
• Use of antidepressants
• Selective serotonin-reuptake inhibitors
(SSRIs) like fluoxetine, paroxetine,
sertraline, fluvoxamine, citalopram
• Tricyclic Antidepressants(TCAs) like
amitriptyline,
• Monoamine oxidase inhibitors
(MAOIs)

36. References
• Young Kimble (2000) et al., Applied Therapeutics: The Clinical Use of Drugs
(7th Ed.), Lipincott Williams & Wilkins, Baltimore, pp 77-77-21.
• Kasper et al., Harrison’s Principle of Internal Medicine (16th Ed.), McGraw and
Hill Companies, New Delhi, pp 2553-2557.
• Boyd Nihart (1998) Psychiatric Nursing Contemporary Practice, Lipincott
Williams and Wilkins, New York, pp 438-472.
• Basavantha BT (2007) Psychiatric Mental Health Nursing (1st Ed.) Jaypee
Brothers Medical Publishers Ltd New Delhi, pp 494-521.
• URL-1: http://
www.who.int/mental_health/management/depression/definition/en/ (Accessed
on October 1, 2010)
• URL-2:
http://en.wikipedia.org/wiki/Major_depressive_disorder#Symptoms_and_signs
• URL-3:
http://www.helpguide.org/mental/depression_signs_types_diagnosis_treatment.

37. THANK YOU