DepressionAssessment

B. Anthony Lindsey, MD
Professor and Vice Chair

SCOPE OF THE
PROBLEM

The Global Burden of Disease

Study reported unipolar
depression as the fourth leading
cause of disability in the world.
Projections for 2020 suggest that
unipolar major depression will be
the second leading cause of
disability worldwide.

Episode Disorder
*Major depression episode
*Major depression episode+
Type I
manic/mixed episode
*Manic/mixed episode

*Major depression disorder

*Bipolar disorder,

*Bipolar disorder, Type I

*Major depressive episode+

Type II
hypomanic episode
*Chronic subsyndromal
depression
*Chronic fluctuations
between subsyndromal
disorder
depression & hypomania

*Bipolar disorder,

*Dysthymic Disorder

*Cyclothymic

If I had __________, Id
be depressed too.

Definitions

Mood - a persons sustained

emotional state

Affect the outward

manifestation of a persons
feelings, tone, or mood

Major Depression

Syndromal classification with

disturbances of mood,
neurovegetative and cognitive
functioning

Major Depression
At least 5 of the following symptoms
present for at least 2 weeks (either
#1 or #2 must be present):
1) depressed mood
2) anhedonia loss of interest or
pleasure
3) change in appetite
4) sleep disturbance

Major Depression
5) psychomotor retardation or agitation
6) decreased energy
7) feeling of worthlessness or
inappropriate guilt
8) diminished ability to think or
concentrate
9) recurrent thoughts of death or
suicidal
ideation

Major Depression
Symptoms cause marked distress and/or
impairment in social or occupational
functioning.

No evidence of medical or substanceinduced etiology for the patients

symptoms.

Symptoms are not due to a normal

reaction to the death of a loved one.

Bereavement and
Late Life Depression
25 35% of widows/widowers meet
diagnostic criteria for major
depressive disorder at 2 months.

~15% of widows/widowers meet

diagnostic criteria for major
depressive disorder at one year.

This figure remains stable throughout

the second year.

Subtypes of Depression
Atypical
Reverse

neurovegetative
symptoms
Mood reactivity
Hypersensitivity to rejection
MAO-Is and SSRIs are more
effective treatments

Subtypes of Depression
Psychotic

(~10% of all MDD)

Delusions common, may have
hallucinations
Delusions usually mood
congruent
Combined antidepressant
and antipsychotic therapy or
ECT is necessary

Subtypes of Depression
Melancholic

No mood reactivity
Anhedonia
Prominent neurovegetative
disturbance
More likely to respond to
biological treatments

Subtypes of Depression
Seasonal

Onset in Fall, remission in

Spring
Hypersomnia is typical
Less responsive to
medications
A.M. light therapy (>2,500 lux)
is effective

Subtypes of Depression
Catatonic

Motoric immobility
(catalepsy)
Mutism
Ecolalia or echopraxia

Epidemiology
Point prevalence

6 8% in women

3 4% in men
Lifetime prevalence

20% in women

10% in men

Epidemiology
Age of Onset

Throughout the life cycle,

typically from the mid 20s
through the 50s with a peak age
of onset in the mid 30s

Epidemiology
Genetics
More prevalent in first degree relatives
3-5x the general population risk
Concordance is greater in monozygotic
(~50%) than dizygotic (~15%) twins
Increased prevalence of alcohol
dependence in relatives

Etiology
Original, clearly over simplistic
theories regarding
norepinephrine and serotonin

Deficiency states
depression
States of excess mania

Problems with initial

theories

Inconsistent findings when studying

measures of these systems: MHPG
(3 methoxy 4 hydroxyphenolglycol)
and 5HIAA (5 hydroxy indoleacetic
acid) in the urine and CSF.
Treatments block monoamine
uptake acutely, however the
positive effects occur in 2-4 weeks.

Receptor theory more

useful

Antidepressant treatment causes

a down regulation in central
adrenergic (beta) and
serotonergic (5HT2) receptors
This change corresponds temporally
to the antidepressant response

Serotonin and
Depression

Decreased CSF levels of serotonin

metabolites
Decreased serotonin transporter
binding
Acute tryptophan depletion can
cause worsening in patients
previously responsive to SSRIs

Gene-Environment
Interactions

Individuals who have one allele for

a low efficiency serotonin
transporter are more vulnerable to
depression after experiencing
environmental stressors (Kendler
2005, Caspi 2003, Lenze 2005)

Neuroendocrine

Hyperactivity of HPA axis:

Elevated cortisol
Nonsuppression of cortisol following dexamethasone
Hypersecretion of CRF

Blunting of TSH response to TRH

Blunting of serotonin mediated increase in
plasma prolactin
Blunting of the expected increase in plasma
growth hormone response to alpha-2 agonists

Functional Neuroimaging (PET,SPECT)

Decreased metabolic activity

Dorsal prefrontal cortex

Anterolateral (concentration,
cognitive processing)
Anterior cingulate (regulation of
mood and affect)

Subcortical
Caudate (psychomotor changes)

Increased metabolic activity

Ventral

prefrontal cortex

Psychosocial

Risk Factors
Poor social supports
Early parental loss
Early life trauma
Female gender
Chronic medical illness
Introversion

Psychosocial

Cognitive Theory
Patients have distorted
perceptions and thoughts of
themselves, the world around
them and the future

Possible to treat by
restructuring

Secondary Causes of
Depression

Toxic
Endocrine
Vascular
Neurologic
Nutritional
Neoplastic
Traumatic
Infectious
Autoimmune

Depression Differential
Diagnosis
Adjustment Disorder with depressed
mood
Maladaptive and excessive response to stress, difficulty
functioning, need support not medicines, resolve as stress
resolves

Dysthymic Disorder
Bipolar Disorder
Other Psychotic Disorders if psychotic

subtype

Personality Disorders (cluster B) Mood

instability with rapid changes is characteristic

Treatment
Biologic
Tricyclic antidepressants
Monoamine oxidase inhibitors
Second generation antidepressants
SSRIs, Venlafaxine, duloxetine,
bupropion, mirtazapine

Electoconvulsive therapy

Treatment
Psychosocial Treatments
Education
Specific psychotherapies
Vocational training
Exercise

Treatment
When to Refer?
Question regarding suicide risk
Presence of psychotic symptoms
Past history of mania
Lack of response to adequate
medication trial

Treatment
Course
One episode 50% chance of
reoccurence
Two episodes 70% chance of
reoccurence
Three or more episodes - >90%
chance of reoccurence

Dysthymic Disorder
Characteristics

Chronically depressed mood for most of the day,

more days than not, for at least two years. Can
be irritable mood in children and adolescents for 1
year
While depressed, presence of at least two of the
following

Poor appetite or overeating

Sleep disturbance
Low energy or fatigue
Low self esteem
Poor concentration
Feelings of hopelessness

Dysthymic Disorder

Never without depressive symptoms for over

2 months
No evidence of an unequivocal Major
Depressive Episode during the first two years
of the disturbance (1 year in children and
adolescents)
No manic or hypomanic episodes
Not superimposed on a chronic psychotic
disorder
Not due to the direct physiologic affects of a
substance or a general medical condition

Epidemiology

More prevalent in women, 4%

prevalence in women, 2% in men
Onset is usually in childhood,
adolescence or early adulthood
Often is a superimposed Major
Depression
High prevalence of substance
abuse in this group

Differential Diagnosis

Other mood disorders

Mood disorder due to a general

medical condition

Treatment

If no superimposed Major
Depression
Psychotherapy

Some evidence suggest

responsiveness to antidepressant
medication in some sub- groups

Course
Prognosis is not as good as
Major Depression in terms of
total symptomatic remission