Transcript Ten Leading Causes of Disability in the World Type of Disability Cost (in DALYs) Cumulative % of Cost Unipolar major depression 42,972 10.3 Tuberculosis 19,673 14.9 Road traffic accidents 19,625 19.6 Alcohol use 14,848 23.2 Self-inflicted injuries 14,645 26.7 Manic-depressive (bipolar) illness 13,189 29.8 War 13,134 32.9 Violence 12,955 36.0 Schizophrenia 12,542 39.0 Iron deficiency.

Ten Leading Causes of
Disability in the World
Type of Disability
Cost (in
DALYs)
Cumulative
%
of Cost
Unipolar major depression
42,972
10.3
Tuberculosis
19,673
14.9
Road traffic accidents
19,625
19.6
Alcohol use
14,848
23.2
Self-inflicted injuries
14,645
26.7
Manic-depressive (bipolar) illness
13,189
29.8
War
13,134
32.9
Violence
12,955
36.0
Schizophrenia
12,542
39.0
Iron deficiency anemia
12,511
42.0
Episode
Disorder
*Major depression episode
*Major depression disorder
*Major depression episode+
manic/mixed episode
*Bipolar disorder, Type I
*Manic/mixed episode
*Bipolar disorder, Type I
*Major depressive episode+
hypomanic episode
*Bipolar disorder, Type II
*Chronic subsyndromal
depression
*Dysthymic Disorder
*Chronic fluctuations
between subsyndromal
depression & hypomania
*Cyclothymic disorder
“If I had __________, I’d
be depressed to.”
Definitions
• Mood - a person’s sustained emotional state
• Affect – the outward manifestation of a
person’s 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 patient’s
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-I’s and SSRI’s 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 20’s through the 50’s with a peak
age of onset in the mid 30’s
Epidemiology
Genetics
 More prevalent in first degree relatives
3-5x the general population risk
 Concordance is greater in monozygotic than
dizygotic twins
 Increased prevalence of alcohol dependence
in relatives
Etiology
Original, clearly over simplistic theories
regarding norepinephrine and serotonin


Deficiency states
States of excess
depression
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 and
serotonergic receptors
– This change corresponds temporally to the
antidepressant response
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)
demonstrates decreased metabolic activity in

Dorsal prefontal cortex
– Anterolateral (concentration, cognitive
processing)
– Cingulate (regulation of mood and affect)

Subcortical
– Caudate (psychomotor changes)
Psychosocial

Risk Factors
– Poor social supports
– Early parental loss
– Introversion
– Female gender
– Recent stressor (especially medical
illness)
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
Other Mood Disorders

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 Type – “glass is half empty type”
overall pessimistic, depressed outlook. Chronic
and longstanding with no change in function.

Treatment
Biologic
 Tricylclic antidepressants
 Monoamine oxidase inhibitors
 Second generation antidepressants
– SSRI’s, Venlafaxine, bupropion, martazapine

Electoconvulsive therapy
Treatment
Psychosocial Treatments
 Education
 Specific pscychotherapies
 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 hypermanic 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
Course
Prognosis is not as good as Major
Depression in terms of total symptoms
remission
Bipolar Disorder
Characteristics of a Manic Episode
 A distinct period of abnormally and persistently
elevated, expansive or irritable mood
 During the period of mood disturbance, at least
three of the following symptoms have persisted
(four if the mood is only irritable) and have been
persistent to a significant degree
–
–
–
–
Inflated self esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas or subjective experience that thoughts
are racing
Characteristics (Cont.)
– Distractability, i.e. attention too easily drawn to
unimportant or irrelevant external stimuli
– Increase in goal-directed activity or
psychomotor agitation
– Excessive involvement in pleasurable activities
which have a high potential for painful
consequences, e.g. unrestrained buying sprees,
sexual indiscretions, or foolish business
investments
Characteristics (Cont.)




Mood disturbance sufficiently severe to cause marked
impairment in occupational functioning or in usual
social activities or relations with others, or to
necessitate hospitalization to prevent harm to self or
others
At no time during the disturbance have there been
delusions or hallucinations for as long as two weeks in
the absence of prominent mood symptoms
Not superimposed on schizophrenia,
schizophreniform disorder, or delusional disorder or
psychotic disorder NOS
The disturbance is not due to the physiologic effects of
a substance or general medical disorder
Presentations of Bipolar Disorder

Manic

Depressed

Mixed
Types

Type I - manic/mixed episode +/- major
depressive episode

Type II - hypomanic episode + major
depressive episode
Epidemiology
Lifetime prevalence
 Type I - 0.7 - 0.8%
 Type II - 0.4 - 0.5%
– Equal in males and females
– Increased prevalence in upper socioeconomic
classes

Age of Onset
– Usually late adolescence or early adulthood.
However some after age 50. Late onset is more
commonly Type II.
Genetics

Greater risk in first degree relatives
(4-14 times risk)
 Concordance in monozygotic twins >85%
 Concordance in dyzygotic twins – 20%
Secondary Causes of Mania
Toxins

Drugs of Abuse
– Stimulants (amphetamines, cocaine)
– Hallucinogens (LCD, PCP)

Prescription Medications
– Common: antidepressants, L-dopa, corticosteroids
Neurologic

Right-sided CVA
 Right frontotemporal tumors
 Huntington’s Disease
 Multiple Sclerosis
Secondary Causes of Mania
(Cont.)
Infectious

Neurosyphilis
 HIV
Endocrine

Hypothyroidism
 Cushing’s Disease
Cyclothymic Disorder
Other Psychotic Disorders
Treatment


Education and Support
Medication
1. Lithium
2. Carbamazepine
3. Valproate
4. Lamotrigine
5. ECT
Course

Acute Episode
– Manic - 5 weeks
– Depressed - 9 weeks
– Mixed - 14 weeks

Long Term
– Variable - most cover fully
– Mean number of lifetime episodes 8-9
Cyclothymic Disorder
Characteristics

For at least two years (one for children and
adolescents) presence of numerous Hypomanic
Episodes and numerous periods with depressed
mood or loss of interest or pleasure that did not
meet criterion A of a Major Depressive Episode
 During a two year period (one year in children and
adolescents) of the disturbance, never without
hypomanic or depressive symptoms for more than
a two month time
Characteristics (Cont.)

No clear evidence of a Major Depressive Disorder,
or Manic Episode during the first two years of the
disturbance (or one year for children and
adolescents)
 Not superimposed on a chronic psychotic disorder,
such as schizophrenia or Delusional Disorder
 Not due to the direct physiologic affects of a
substance or a general medical condition
Epidemiology
Lifetime prevalence 0.4 – 1.0 %
same for males and females
 Age of onset

– Usually in adolescence or early adulthood

Genetics
– Major Depression and Bipolar Disorder more
common in first degree relatives
Cyclothymic Disorder
Secondary causes of cyclothymic disorder

Bipolar Disorder
 Mood disorders due to a general medical condition
Treatment

Initiation of biologic treatment is dependent on the
degree of impairment
 If treatment is indicated, it is similar to that of
Bipolar Disorder
Episode
Disorder
*Major depression episode
*Major depression disorder
*Major depression episode+
manic/mixed episode
*Bipolar disorder, Type I
*Manic/mixed episode
*Bipolar disorder, Type I
*Major depressive episode+
hypomanic episode
*Bipolar disorder, Type II
*Chronic subsyndromal
depression
*Dysthymic Disorder
*Chronic fluctuations
between subsyndromal
depression & hypomania
*Cyclothymic disorder