DEPRESSION

SADNESS
•Mild & temporary
•Intense & long lasting
•Far end of sadness = depression
DEPRESSION (FEATURES)
• Sadness lingers for long time
• Social withdrawal
• Disruption in functioning
• Trouble in eating (↑↓), sleeping (↑↓), concentrating
• Feel responsible for things beyond control
• Lose pleasure in things once enjoyed (Anhedonia)
• Fatigue
• Hopelessness
• Self harm or suicidal ideas
• Crying spells
• Cognitive symptoms- worthlessness,
indecisiveness
• Physical/Somatic symptoms- sleep, appetite ,
energy disturbances
• Affective symptoms- loss of interest
 MAJOR DEPRESSIVE EPISODE
• absence of manic, or hypomanic episodes before or
during the disorder
• Lasts for at least 2 weeks
• + symptoms mentioned earlier
• Early morning wakening (wake up very early, keep
lying on bed)
• Slowness, trouble gathering physical energy
• Guilt, worthlessness, indecisiveness
NNHN HJ
 MAJOR DEPRESSIVE DISORDER/
UNIPOLAR DEPRESSION (SINGLE
EPISODE)
• Rate severity- mild,
moderate severe
• A 2-month interval of normal mood
must occur for episodes to be
considered separate from one
another

• 8 specifiers
SPECIFIERS OF MDD
 1. PSYCHOTIC FEATURES
• In the midst of episode, develop hallucinations &
delusions
• Mood congruent (voices telling how useless they
are)
• If mood incongruent (grandiosity) & depression
schizophrenia
• poor response to treatment, greater impairment,
and fewer weeks with minimal symptoms
2. ANXIOUS DISTRESS SPECIFIER

•Comorbid anxiety disorder or anxiety

symptoms
•More likely-- suicide
3. MIXED FEATURES SPECIFIER

•several (at least three) symptoms of

mania
4. MELANCHOLIC FEATURES SPECIFIER

• full criteria for a major depressive episode have

been met
• severe somatic (physical) symptoms, such as
early-morning awakenings, weight loss, loss of
libido (sex drive), excessive or inappropriate
guilt, and anhedonia
 5. CATATONIC FEATURES SPECIFIER

• absence of movement (a stuporous

state) or catalepsy, in which the
muscles are waxy and semirigid, so
a patient’s arms or legs remain in
any position in which they are placed
• excessive but random or purposeless
movement
• Common in depression (common
“end state” reaction to feelings of
imminent doom freeze when being
attacked) & schiz
6. ATYPICAL FEATURES SPECIFIER

• oversleep
• Overeat
• can react with interest or pleasure to some things,
unlike most depressed individuals
• More severe symptoms, alcohol abuse,
comorbidities
 7. PERIPARTUM ONSET SPECIFIER
• “surrounding”, in this case the period of time just before and just after the
birth
• postpartum (after the birth)
• More minor reactions in adjustment to childbirth— “baby blues”—
typically last a few days after delivery
• difficulty understanding why she is depressed, because they assume this
is a joyous time.
• Stressed because of physical exhaustion, new schedules, adjusting to
nursing & other changes following birth
• Hormonal changes
8. SEASONAL PATTERN SPECIFIER
• Applies to recurrent major depressive disorder & to bipolar disorders
• accompanies episodes that occur during certain seasons (for example, winter depression)
• depressive episode that begins in the late fall/ autumn and ends with the beginning of
spring
• In bipolar disorder, individuals may become depressed during the winter and manic
during the summer.
• episodes must have
• occurred for at least two years with no evidence of non seasonal major depressive
episodes occurring during that period of time.
• excessive sleep (rather than decreased sleep) and increased appetite and weight gain
(rather than decreased appetite and weight loss)
• related to daily and seasonal changes in the production of melatonin, a
hormone secreted by the pineal gland.
• exposure to light suppresses melatonin production, it is produced only at
night.
• Melatonin production also tends to increase in winter, when there is less
sunlight.
• increased production of melatonin might trigger depression in vulnerable
people
• phototherapy, a current treatment, most patients are exposed to 2 hours of
bright light (2,500 lux) immediately on awakening
(Recurrent) major Depressive Disorder
• If two or more major depressive episodes occurred and
were separated by at least 2 months during which the
individual was not depressed
DYSTHYMIA
• Persistent depressive disorder
• Fewer symptoms (as few as 2)
• Depression remains unchanged for long periods
• Depressed mood continues for at least 2 yrs
• Cant be symptom free for more than 2 months
• Intensity & chronicity different from MDD
• Double depression= MD episodes+ persistent depression with fewer
symptoms
Double depression
•both major depressive episodes and
persistent depression with fewer symptoms
 PREVALENCE
• population-based study from South India, screened more than 24,000
subjects in Chennai using Patient Health Questionnaire (PHQ)-12
reported overall prevalence of depression to be 15.1% using the 2001
census data (Poongothai et al., 2009)
• more common in women, younger subjects, poor economic
background, poor nutritional status, Muslims, divorced or widowed,
residing in nuclear families and urban areas, unemployed condition,
low educational level
• Depression in the elderly had significant association with
female gender, not being consulted for major decisions,
presence of any chronic morbidity, spending day without
doing any activity, work or hobby, and death of any close
relative in the last 1 year
• prevalence of depression in the elderly was 14.4% in a
rural community of north India.
• length of depressive episodes is variable, with
some lasting as little as 2 weeks;
• in more severe cases, an episode might last for
several years, with the typical duration of the
first episode being 2 to 9 months if untreated
• typical age of onset has been estimated to be in the
early 20s
• onset before 21 years of age, and often much
earlier, is associated with: (1) greater chronicity (it
lasts longer), (2) relatively poor prognosis (response
to treatment), (3) stronger likelihood of the disorder
running in the family of the affected individual.
GRIEF
• Grieving= natural way of confronting and handling loss
• Usually natural grieving process first 6 months
• some people may grieve for a year or longer (Currier, Neimeyer, & Berman,
2008; Maciejewski et al., 2007)
• acute grief evolves into integrated grief, in which the finality of death and its
consequences are acknowledged and the individual adjusts to the loss.
• complicated grief- difficulty regulating their own emotions, which tend to
become rigid and inflexible
• Diagnosis requiring further study
OTHER DEPRESSIVE DISORDERS
PREMENSTRUAL DYSPHORIC DISORDER

• severe and sometimes incapacitating emotional

reactions during the premenstrual period
• combination of physical symptoms, severe mood
swings and anxiety are associated with incapacitation
during this period of time
• disorder of mood
DISRUPTIVE MOOD DYSREGULATION DISORDER
• Chronic irritability
• Anger
• Aggression
• Hyperarousal
• Temper tantrums
• No mania
• Difficulty regulating emotions
CAUSES/
ETIOLOGY
BIOLOGICAL
FACTORS
 GENETICS

• Accounts for 39-50% of depression symptoms

• Depression runs in families (twin studies; family studies)
• Genes on chromosome 17 involved in serotonin production involved.
serotonin-transporter gene—a gene involved in the transmission and reuptake
of serotonin, one of the key neurotransmitters involved in depression.
• Oligogenic transmission
•
BRAIN FEATURES

• Low activity in LH (reduced positive affect & approach beh to rewarding stimuli, high activity in
RH increased anxiety & increased NA, hypervigilance)
• Reduced activity & size changes in prefrontal * other cortical areas
• Highly active Amygdala (anxiety), hippocampus, caudate nucleus, anterior cingulate cortex
(involved in goal directed behavior & inhibition of negative mood & troublesome thoughts,
memory difficulties)
• Damage to white matter, basal ganglia & pons (involved in regulating attention, motor
behavior, memory, emotions)
 NEUROCHEMICALS & HORMONES
• monoamine theory of depression— that depression was at least sometimes due to an absolute or
relative depletion of neurotransmitters norepinephrine & serotonin at important receptor sites in the
brain (Schildkraut, 1965).
• Low serotonin
• Low norepinephrine
• Low dopamine (pleasure)
• Increased cortisol (Elevated activity of HPA axis: CRH from hypothalamus ACTH from pituitary
cortisol from adrenal glands in stress– poor feedback process of HPA) cell death in hippocampus
memory lapses
• Low thyroid hormone
• Suppressed growth hormone, somatostatin & prolactin
SLEEP DEFICIENCIES

• Enter rapid eye movement sleep more quickly

• Display less slow wave or deep sleep than normal
• Intense but less stable REM sleep
• Disrupt sleep & cause fatigue
• Disruption in internal sleep wake cycle (Circadian rhythm)
when sunlight less available to regulate it in early morning
wakening or depression in winter months
PSYCHO SOCIAL
FACTORS
STRESSFUL LIFE EVENTS

•Early adversity- family turmoil, parental

psychopathology, physical or sexual abuse, and
other forms of intrusive, harsh, and coercive
parenting
• dysfunctional early parenting, emotional abuse, and
parental loss
• gene–environment correlation model (Kendler, 2011;
Kendler, Jaffee, & Roemer, 2011)
• people who tend to seek difficult relationships because
of genetically based personality characteristics that
then lead to depression
• individuals vulnerable to depression who are placing
themselves in high-risk stressful environments, such as
difficult relationships or other risky situations where
bad outcomes are common.
• Learned helplessness theory of depression (Abramson,
Seligman & Teasdale, 1978)
• Depressive attributional style===
• internal, individual attributes negative events to
personal failings (“it is all my fault”)
• stable, even after a particular negative event passes,
the attribution that “additional bad things will
always be my fault” remains
• global, attributions extend across a variety of issues
COGNITIVE DIATHESES

•people who attribute negative events to

internal, stable, and global causes
•pessimistic or depressive attribution
• Negative cognitive
styles
• Catastrophic
thinking
• Cognitive
distortions/ biases
 PERSONALITY

• Neuroticism/ negative affectivity= stable and heritable

personality trait that involves a temperamental sensitivity
to negative stimuli- sadness, anxiety, guilt, hostility
• High level of introversion
• Low positive affectivity feel unenthusiastic, unenergetic,
dull, flat, bored
INTERPERSONAL FACTORS

•Deficits in social skills

•Deficits in communication skills
•Marital problems
• conflict within a marriage  different effects on
men and women
FAMILY FACTORS
• Impaired attachment to parents at early age overdependence on others,
fear of abandonment, poor self worth, self criticism, anger towards self &
parent
• Sibling fights
• Maltreatment/ abuse
• Depressed mothers inadequate parenting= high criticism, less affection
• Depressed fathers inadequate parenting= indecisive, cynical, irritable
• Child models parents & develops negative self view
• Expressed emotion= hostility+ conflict + overinvolvement
CULTURAL FACTORS

•High in migrants
•Gender roles
• 70% of the individuals with major depressive disorder and
dysthymia are women (Hankin & Abramson, 2001; Kessler, 2006;
Kessler & Bromet, 2013).
• Bipolar equal in men & women
• culturally induced dependence and passivity may well put women at
heightened risk for emotional disorders by increasing their feelings of
uncontrollability and helplessness. (men independent, women
dependent)
• Women place greater value on intimate relationships than men, which
can be protective if social networks are strong
• Disruption in SS network can be devastating too
• Women ruminate & self blame more than men
• Men ignore feelings & distract themselves
EVOLUTIONARY INFLUENCES

• Depression evolved so as to help withdraw from social

interactions when person feels low value/ burden on
others/ at risk for social exclusion
• Depression evolved to ruminate over problems until a
solution found
• Depressive behaviors= signal to others for help
• Withdrawal helps lower stress
THEORETICAL
PERSPECTIVES
PSYCHODYNAMIC (FREUD & ABRAHAM)

• Depression= anger turned inwards

• In response to imagined or symbolic loss
• when a loved one dies mourner regresses to the oral stage of
development (when infant cannot distinguish self from
others) introjects or incorporates lost person
• A typical scenario regarding how this transformation was thought to play out may be helpful is further
explaining this theory. Neurotic parents who are inconsistent (both overindulgent and demanding),
lacking in warmth, inconsiderate, angry, or driven by their own selfish needs create a unpredictable,
hostile world for a child. As a result, the child feels alone, confused, helpless and ultimately, angry.
However, the child also knows that the powerful parents are his or her only means of survival. So, out
of fear, love, and guilt, the child represses anger toward the parents and turns it inwards so that it
becomes an anger directed towards him or herself. A "despised" self-concept starts to form, and the
child finds it comfortable to think thoughts along the lines of "I am an unlovable and bad person." At
the same time, the child also strives to present a perfect, idealized (and therefore acceptable) facade
to the parents as a means of compensating for perceived weaknesses that make him or her
"unacceptable". Caught between the belief that he or she is unacceptable, and the imperative to act
perfectly to obtain parental love, the child becomes "neurotic" or prone to experiencing exaggerated
anxiety and/or depression feelings. The child also feels a perpetual sense that he or she is not good
enough, no matter how hard he or she tries.
• This neurotic need to please (and perpetual failure to do so) can easily spread beyond the situation in
which it first appears, such that the child might start to feel a neurotic need to be loved by everyone,
including all peers, all family members, co-workers, etc. The goal of a traditional psychodynamic
psychotherapy might be to help the child (now an adult in therapy) to gain insight into the mistaken
foundations of his or her belief in his or her badness and inadequacy so that the need to punish
himself/herself and to be perfect decreases.
• According to object relations theory, depression is caused by problems people have in developing
representations of healthy relationships. Depression is a consequence of an ongoing struggle that
depressed people endure in order to try and maintain emotional contact with desired objects. There
are two basic ways that this process can play out: the anaclitic pattern, and the introjective pattern.
Even though these terms are not currently used in the DSM, some therapists may still use them to label
different types of depression.
• Anaclitic depression involves a person who feels dependent upon relationships with others and who
essentially grieves over the threatened or actual loss of those relationships. Anaclitic depression is
caused by the disruption of a caregiving relationship with a primary object and is characterized by
feelings of helplessness and weakness. A person with anaclitic depression experiences intense fears
of abandonment and desperately struggles to maintain direct physical contact with the need-
gratifying object.
• Introjective depression occurs when a person feels that they have failed to meet their own standards
or the standards of important others and that therefore they are failures. Introjective depression
arises from a harsh, unrelenting, highly critical superego that creates feelings of worthlessness, guilt
and a sense of having failure. A person with introjective depression experiences intense fears of
losing approval, recognition, and love from a desired object.
BEHAVIORAL THEORIES

• Depression when responses no longer produce positive

reinforcement or
• when negative experiences increases (such as when
experiencing stressful life events)
• receive fewer positive verbal and social reinforcements from
their families and friends
COGNITIVE THEORIES

• cognitive symptoms
of depression often
precede and cause
the affective or
mood symptoms
• depressogenic schemas-- rigid, extreme, and
counterproductive (I am not good if I don’t do everything
perfectly) underlie dysfunctional beliefs
• Negative life experiences/ vulnerability + stressful life
event negative automatic thought pattern created (thoughts
that often occur just below the surface of awareness and
involve unpleasant, pessimistic predictions)
• Pessimistic predictions centre around negative cognitive triad
• Cognitive distortions maintain negative cognitive triad
• Helplessness & hopelessness theory
• Pessimistic attributional styles- global and stable attributions for negative
events + make negative inferences about likely negative consequences of the
event + negative inferences about the implications of the event for the self-
concept
• Ruminative response styles (Nolen-Hoeksema & hilt, 2009)
• different kinds of responses that people have when they experience feelings
and symptoms of sadness and distress, and how their differing response styles
affect the course of their depressed feelings
• Rumination= pattern of repetitive and relatively passive mental activity rather
than being action oriented, problem solvers
PREVENTION
• Identify your strengths
• Modify negative & irrational thoughts
• Develop Problem solving skills
• Use social support
• Recognise others’ perspective
• Learn stress management techniques
• Time management
• Building & maintaining self confidence & self esteem
• Seek help (psychological or psychiatric)