By

Dr Pavan Kumar Kadiyala, MD (Psy)

Consultant Psychiatrist,
Vijayawada
Index
World Health Day: When, Why, What
Why Depression chosen as campaign slogan in 2017
Epidemiology of depression in World and India
How to find depression: case vignettes
Theory on depression
Cause and consequences of depression
Stigma and Anti-stigma interventions
Management of depression
Myths in depression
World Health Day

a global health awareness day celebrated every year on 7 April

mark the anniversary of WHO's founding,
to draw worldwide attention and mobilize action around a specific
health topic of global concern.
organizes international, regional and local events on the Day related
to the theme.
 2016 Diabetes
2015 Food safety
2014 Vector-borne diseases
2013 Focus on high blood pressure
2012 Active ageing: Good health adds life to years
2011 Antibiotic resistance: No action today, no cure tomorrow
2010 1000 cities, 1000 lives
2017 World Health Day
campaign is depression.
WHOs year-long campaign
Depression
the leading cause of ill health and disability worldwide.
more than 300 million people are now living with depression, an
increase of more than 18% between 2005 and 2015. (WHO)
one of five women and one of ten men at some time during their lives.
 The continuing stigma associated with mental illness was the reason
why we decided to name our campaign,
Depression: lets talk,
Dr Shekhar Saxena, Director, Dept of Mental Health & Substance Abuse at WHO.

For someone living with depression, talking to a person they trust is

often the first step towards treatment and recovery.
high-income countries, nearly 50% with
depression do not get treatment.
just 3% health budget invested in
mental health,
<1% in low-income countries to
~5% in high-income countries.
 Investment in mental health makes
economic sense.
Every US$ 1 invested in scaling up
treatment for depression and anxiety
leads to a return of US$ 4 in better
health and ability to work.
 NMHS
large scale, multi-centred national study
across 12 Indian states
Prevalence of mental health problems
aged 18 years and above
 weighted prevalence of depression
current - 2.7% (nearly 1 in 40)
life time - 5.2% (1 in 20 suffer from past and current depression)
amounting to a total of over 45 million persons with depression in 2015
Burden of disease
 India - 18% of the world population, 15% of global DALYs
attributable to mental, neurological and substance use disorders
with depression, accounting for 37% (115 million DALYs) in 2013.
Burden of depression: increased by 67% between 1990 and 2013.
(in terms of DALYs)

projected to rise by roughly 2.6 million (22.5%) by 2025

rapid sociodemographic transition
globalization, urbanization, migration, and modernization
People with depression are 1.52 times more likely to die than the general
population
At its worst, depression can lead to suicide. Suicide is the second leading
cause of death in 15-29-year-olds.
 affect people from all backgrounds
across the life-course, from early childhood to the end stages of life,
with an increased toll at certain time points (post partum)

higher in females,
age-group of 40-49 years
residing in urban metros.
Low income group
Equally high rates among the elderly
3 of 4 persons with depressive disorder experience
significant disability in work, social and family life in
India
Disability
Over 50.0% of individuals reported interfered with their daily activities
Social impact
Family members missed work and leisure activities on an average by 8.5 and 10
days, respectively, in the past 3 months
Economic impact
reduced work functioning,
absenteeism,
impaired productivity,
decreased job retention and
early retirement across a wide variety of occupations
How to find
 Case 1
A married lady aged 29 years, three weeks after giving birth to her 2nd child.
crying spells, loss of interest in activities, feeling tired easily, feeling sad,
difficulty in falling asleep, and inability to look after her baby for 2 weeks
Day prior to presentation, had tried to kill herself by consuming painkillers.
Personal history: marital discord
Past history: had a similar episode following the birth of her first child,
lasting 4 months; was treated in a private hospital with ECTs.
Family history: Alcohol dependence in father.
Premorbid personality: Well adjusted.
(continued)
Physical examination: Normal
Mental status examination:
Sad mood, without reactivity
Ideas of helplessness, hopelessness
Death wishes, suicidal ideas
Denies delusions / hallucinations
Cognitive functions normal
Insight good.
 Case 2
A married man aged 40 brought by wife.
He complains of disturbed sleep, loss of appetite and weight, feeling dull
and sad, worrying about his future, lack of interest in regular activity,
feeling he is a failure, and wanting to die for the last 3 months.
Has not attempted suicide.
Has been consuming alcohol excessively for the last 2 months.
Personal history: alcohol use, not amounting to abuse or dependence.
Past history: Nil
Family history: Nil contributory
Premorbidly: have mood fluctuations.
 (continued)
Physical examination: obese
Mental status examination:
Sad mood, not reactive
Ideas of guilt and death wishes
Delusion of reference people talk about his failures
2nd person auditory hallucinations
Cognitive functions normal,
Insight - present
 Case 3
A married lady aged 39 referred by a physician.
She complains of feeling tired most of the time, feeling sad and irritable on
most days, thinking negatively about her life, difficulty falling asleep,
getting upset and crying easily, and reduced interest in life for the last 4
years.
However, she is able to work as a teacher and look after her family.
never attempted to harm herself, but has thought of it twice in past 2 years.
Personal history: Interpersonal disputes with mother-in-law and sister-in-
law. Alcohol abuse in husband, conduct disorder in eldest son.
Past history: Nil contributory.
Family history: Nil
Premorbidly: tendency to worry excessively, cautious in most situations
 (continued)
Physical examination: midline neck swelling, firm, diffuse,
moving on deglutition.
Mental status examination:
Cooperative and well kempt
Sad mood, but reactive to the environment
Worried about her interpersonal problems
No ideas of worthlessness, hopelessness, death wishes
Insight - good
Case 4
A 70 year old lady with 1 year h/o multiple body aches, headache,
dizziness, burning and tingling sensations in the feet, gives h/o of
constipation. She has been examined by 3 GPs who found no
problem and treated with analgesics and tonics.
Reported no relief from her symptoms and worries about her ill
health.
 Depression
MC psychiatric disorder (15%)
Globally, depression is the top cause of illness and disability among young and middle-aged
populations, while suicide 2 ranks second among causes of death for the same age groups
Males (8-12%), females (20-25%)
Middle aged (25-45yrs)
Clinical features:
depressed/ sad mood (most essential)
Loss of interest/ pleasure
Easy fatigability
Thought: pessimistic thoughts, ideas of hope, help, worthlessness, guilt feeling, loss of
self esteem, suicidal ideas, hypochondriasis, delusion of nihilism, poverty, guilt..
 PMA: retardation, depressive stupor
Cognition: poor concentration, impaired memory pseudodementia
Hopelessness most definitive indicator
Somatic/ melancholic symptoms (melancholia in old age involutional melancholia
disturbances in biological functions
Psychotic symptoms (psychotic depression) in severe depression= 15-20% pts AH,
delusions (mood congruent/ incongruent)
 Depression facies
Long
Eye brows drawn down
Mouth is lower,
Corners of mouth are lower, relative to outer canthi of the eyes
Veraguths sign:
triangular fold in nasal corner of upper eye lid
Omega sign:
wrinkling above nose and b/w eye-brows resembling omega
 MDD - criteria
5 of 9 every day for 2 wks
(1 must be either depressed mood or loss of pleasure)
SIG E CAPSS
Sad/depressed mood
Interest decreased (anhedonia)
Guilt feeling/ worthlessness
Energy decreased
Conc difficulties
Appetite disturbances/ wt loss/gain
Pschomotor reatardation/ agitation
Sleep disturbances
(initial, middle,terminal, not refreshing)/
suicidal thoughts
 Children:
irritability, tantrums,
physical complaints (headache, stomach ache),
sadness and tearfulness, feeling bored, separation anxiety
poor academic performance and disturbed family relations.
Elderly
Melancholia
Psychomotor agitation/ retardation
Psychotic features (delusion of nihilism, guilt, hypochondriasis,
Hallucinations)
 MELANCHOLIA
MELAN
Morning worsening of sym, psychoMotor agitation/retardation, early Morning
wakening
Excessive guilt
Loss of emotional reactivity
ANorexia, ANhedonia

Others:
Decresed libido
 Atypical features
mood reactivity (mood brightens in response to positive events)
Significant wt gain or inc in appetite
Hypersomnia
Leaden paralysis (ie heavy, leaden feelings in arms or legs)
Interpersonal rejection sensitivity (not limited to mood sym) disturbed SOF
 Seasonal pattern seasonal affective disorder
Applies to RDD
Regular temporal relationship b/w onset of episode & a particular time of year
Full remissions also occur at a characteristic pattern of the year
2 episodes in last 2 yrs
Begin in Nov & end in march (WINTER DEPRESSION)
Role of melatonin
Rx: phototherapy with light box (1,500 10,000 lux)
 Peri-partum disorder
3-6% of women experience the onset of MDD during pregnancy or within 4 wks
following delivery
Post partum psychiatric disorders:
Post-partum blues: 80%
Normal irritability with a few sym
Benign
Starts 3-4days, peak 5-7days, resolves in 2nd wk
Post partum depression
Post partum psychosis: mood episode with psychosis in primipara
Duration: after 3rd day, if earlier in 72 hrs, rule out organicity (delirium)
MC postpartum sym: Post-partum blues
MC postpartum illness: Post partum depression
MC to recur: Post partum psychosis
 PMDD
Premenstrual dysphoric disorder/ premenstrual tension
5 out of 11 symptoms in final wk before onset of menses, improving within few days
of onset & become minimal in the week postmenses; for 2 cycles
Marked mood lability (mood swings, rejection sensitivity)
Marked irritability/ interpersonal conflicts
Depressed mood/ hopelessness
Marked anxiety, tension/ feeling on edge
Decreased interest; Difficulty conc; Easy fatigability; Appetite changes/ food cravings,
Sleep changes
A sense of out of control
Physical symptoms: breast tenderness/ swelling, joint/muscle pain, sensation of
bloating/wt gain
 Endogenous
caused by internal factors
Produces biological symptoms
Insomnia, loss of appetite, wt loss
There may be psychotic symptoms
 Reactive (neurotic)
Exogenous depression
Adjustment disorder
Precipitated by external events or stressors
Stressor depressive state mood responsive in accordance of stressor
No very mild biological symptoms
Psychotic features are absent

Neurotic also used to describe chronic minor depression (dysthymia)

Neurotic depression
Exogenous or reactive depression
dysthymia
 AGITATED depression
With marked motor restlessness as agitation
MC after 40yrs of age.
 Depression
MC psychiatric disorder in
Pt with AIDS
Post partum
Hypothyroidism (myxedema)
After surgery
After attack of MI/stroke
 Disruptive mood dysregulation disorder

In children upto 12 yrs of age.

Persistent irritability
Frequent Episodes of extreme behavioral dyscontrol (temper outburst)
Typically develop unipolar depressive or anxiety disorders as they mature into
adolescence and adulthood
 Suicide in depression
MC cause: depression (15-20%)
2nd MC cause: alcoholism
SAD PERSONS (mnemonic)

MC in endogenous, psychotic, involutional depression

MC phase of depression for suicide: depression in recovery
Methods used: poison ingestion followed by hanging, burning, drowning, jumping
Psychological autopsy is done for suicide
 Suicide Mnemonic
Sex: Male (attempts common in female, completion common in males)
Age: 15-25yrs or 59+yrs
Depression or hopelessness
Previous attempt or psychiatric care
Ethanol or drug use
Rational thinking loss (psychotic or organic illness) (schiz)
Single, widowed, divorced
Organized or serious attempt
No social support
Stated future intent (determined to repeat or ambivalent)
 Somatized depression
Somatization and Cultural Idioms of Distress
most primary care patients with major depression or anxiety disordrs (70%80%)
present exclusively with multiple somatic complaints
increase attention to and concern about bodily sensations
Chest pain, atypical facial pain, generalized weakness, paresthesias, heaviness of head
MC being - musculoskeletal pain and fatigue
MASKED depression:
depressed mood is not easily apparent & usually hidden behind somatic symptoms
Causes of depression
Depression is both a cause and consequence of several
noncommunicable diseases, substance use disorders
and nutritional disorders.
SECONDARY DEPRESSION

Neurological Disorders
Poststroke Depression
prevalence - 6% to 34% (19% in hospitalized and 23% in outpatients)
Onset - just under a year, with peak incidence b/w 3 - 6 months post CVA
Parkinsons Disease
as high as 40%
Multiple Sclerosis
40% of the subjects with multiple sclerosis had clinically significant depressive symptoms and
about one-third likely had moderate to severe depression
Epilepsy
MC comorbid psychiatric disorder in patients with epilepsy (6-30%)
 Cancer
Up to one-quarter of patients with cancer
6% to >40%
Certain types of cancers may have higher incidences
Ca Breast 10%-33%
Patients and physicians have a tendency to ignore and neglect depressive
symptoms in cancer patients (Croyle and Rowland 2003).
Heart Disease
>2/3rd surviving a MI/ CAD/CHF experience some type of depression
Conversely, a reciprocal relation exist as well,
persons with depression are likely to be at increased (double) risk for heart
disease.
affects rhythmicity, BP, clotting factors, and also insulin and cholesterol levels.
also may chronically increase stress hormones, cortisol and epinephrine
may affect a persons health status, influencing compliance with
medications, or other health-related behaviors such as smoking and
exercise
Diabetes
Diabetes,double ones risk for depression;
severity of the diabetes correlate with the risk of depression
relation between diabetes and depression?
a direct causal mechanism, in which the endocrine (or other) abnormalities
also trigger a depressive episode.
The same stress hormones that are involved in the regulation of glucose are
also likely involved in the regulation of stress and mood
Evidence indicates that treatment of depression in patients with
diabetes can improve their diabetic control
Thyroid Disease
15% of depression have at least mild hypothyroidism
Although treating the hypothyroidism as part of depression treatment
is essential,
symptoms of depression sometimes persist beyond correction of the thyroid
and require specific antidepressant treatment
 Irritable Bowel Syndrome
Tinnitus
Fibromyalgia
Sleep Apnea
Associated with chronic communicable diseases
likeTB, HIV and others
hypertension, thyrotoxicosis, bronchial asthma, rheumatoid arthritis,
peptic ulcer, ulcerative colitis, and neurodermatitis
Stigma

devastating consequences for patients and their families.

False beliefs and negative attitudes
with a substantial proportion of the general public agreeing that people with
these types of problems are a danger to others, can be erratic in their
behaviour and should be avoided
why try effect : anticipated discrimination in 2037% of persons
enacted stigma: a higher rate of experienced discrimination - 79%
 educating the general public to improve their mental health;
empowering patients to enhance their pursuit of social participation;
educating, empowering and supporting the caregivers;
improving workplace interventions;
providing social contact and care programme for health care
providers and creating responsible media.
 Firstly
(i) early recognition;
(ii) appropriate and effective treatment,
pharmacological and nonpharmaclogical interventions; and
(iii) continuity of care and adequate follow up for reducing relapse and
chronic course of the illness.
Secondly, services for depression should be integrated within the
existing health system
Thirdly, awareness and demand for service in the community should
be increased through health education.
 Myth 1: Psychiatric disorders are personal weaknesses or a
personality flaw
Myth 2: Mental health disorders affect very few people
Myth 3: Once a psychiatric patient, always a psychiatric patient
Myth 4: Children dont suffer from psychiatric illnesses
Myth 5: Mental health disorders are a result of bad parenting:
Myth 6: Mental illnesses are contagious
Myth 7: Attempting suicide is a sign of cowardice
 THANK YOU
 Depression can be effectively managed with pharmacological means
(antidepressant medications) and psychotherapeutic means
(counselling or therapy) or a combination of both, depending on the
severity of the condition along with interventions that promote
healthy lifestyles.
In the management of mild depression, psychotherapy and
counselling is the treatment of first choice rather than 76
pharmacologic means