Depression: : Depression: What is it? Alec Bodkin, M.D., Chief
Clinical Psychopharmacology
Research Program
McLean Hospital, Belmont, MA
Depression is ancient: : Depression is ancient:
Aretaeus of Capadocia (150-200 AD):
“The patients are dull or stern: dejected or unreasonably torpid, without any manifest cause…”
Aretaeus : Aretaeus “They become peevish, dispirited, sleepless, and start up from a disturbed sleep. Unreasonable fears also seize them...”
Aretaeus : 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.”
Depression is worldwide : 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
Depression is physically as well as psychologically impairing : 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
“…depressive illness is probably more unpleasant than any disease except rabies.” JS Price, Chronic depressive illness, British Med J, 1978 : “…depressive illness is probably more unpleasant than any disease except rabies.” JS Price, Chronic depressive illness, British Med J, 1978
Silent epidemic : 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
The daily experience : The daily experience
In 1990- 1992 in the US : 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
In 2000-2002 in the US : 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
The Diagnosis of Major Depression : 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
Common depressive symptoms : Common depressive symptoms Helplessness
Brooding
Passivity
Pessimism
Social Withdrawal
Tearfulness Poor memory
Neediness
Irritability
Bodily discomfort
Hypochondria
Loss of sexual interest
Subtypes of Depression : 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.
Subtypes of Depression : 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.
Subtypes of Depression : 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
Subtypes of Depression : 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)
Subtypes of Depression : 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
Subtypes of Depression : Subtypes of Depression SEASONAL DEPRESSION: Episodes follow seasonal pattern
Onset in Fall, recovery in Spring.
Wintertime carbohydrate craving, oversleeping, low energy, social withdrawal.
Subtypes of Depression : 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
Depressive Subtypes under study : 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
>2 day < 2 week frequent major depressive spells, no mania, not premenstrual
Depressive Personality Disorder
Only psychological symptoms, consistently present since adolescence
Course of Depressive Illness : 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.
Course of Depressive Illness : Course of Depressive Illness Average age of first depression: mid 20’s (Has been getting earlier since 1940)
Untreated episodes may last 4 months to 2 years
20% become chronic
Course of Depressive Illness : 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)
Familial Risk: : 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
Comorbidity : 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
Biology of Depression : 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
Biology of Depression : 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).
Genetic Vulnerability : 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
Summary : 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
Summary : 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