3.4 Affective Disorders Literature
PROBLEM 1: DEPRESSION PT. 1
WHAT IS DEPRESSION? - OVERVIEW
Time for united action on depression: a Lancet-World Psychiatric Association
Commission (Herrman et al.)
Key messages and recommendation regarding depression
1. Depression is a common, but poorly recognized and understood health condition
Brings profound suffering to those both directly and indirectly affected by it
2. Depression is a heterogeneous entity experienced with various combinations of signs and symptoms,
severity levels, and longitudinal trajectories
Although usually classified as a binary disorder, depression has a diversity of clinical presentations,
severity levels, and longitudinal courses
Commonly overlaps with other conditions
3. Depression is universal, but culture and context matter
Anhedonia, depressed mood and fatigue are common, however there is considerable variability in
types and prevalence of symptoms among cultures
It's core features have been thoroughly described over centuries, which goes against the premise
that it is an exclusively modern problem
4. Prevention is essential to reducing the burden of depression globally
5. The experiences of depression and recovery are unique for each individual
Depression is the result of a set of factors, typically the interaction of proximal adversities with
genetic, social, environmental, and developmental risk and resilience factors
Requires at least mildly personalized treatments in order to work
6. Closing the care gap requires engagement of people with lived experience
Most people w/depression do not receive effective care due to a range of demand and supply
barriers
7. A formulation is needed to personalize care
Detection of depression on the basis of symptoms should be accompanied by a clinical review or
formulation, which takes into account individual circumstances
The complexity of the formulation can vary depending on the context of care and availability of
resources
8. A staged approach to care addresses the heterogenous nature of depression and its impacts on
individual, family, and community functioning
Offers a pragmatic tool to translate the heterogenous clinical nature of depression for management
Ensures the interventions are comprehensive but proportional to the individual severity
Facilitates a focus on intervening early in the course of the condition and graduating the intensity of
interventions
Looks at depression along a continuum
9. Collaborative deliver models are a cost-effective strategy to scale up depression interventions in
routine care
Collaborative care offers and evidence-based approach for the delivery of interventions by diverse
providers, tailored to the specific stage of the illness
3.4 Affective Disorders Literature 1
, 10. Increased investment with whole-of-society engagement is a priority to translate current knowledge into
practice and policy and to upgrade the science agenda
Introduction
Despite robust evidence of interventions many factors hamper the effectiveness of interventions
Most people affected by mental health problems do not receive appropriate interventions
Depression as an omnipresent experience that is difficult to narrow down to discrete frames as it involves
many deeply personal experiences
Diagnostic frames are useful, but we can't get overly attached to them as they can't encompass what it
is like to experience depression
Concept of depression refers to → condition that arises from multiple constellations of factors that operate
in various ways with widely different outcomes
Two expressions to describe the experience of depression
People with depression
Patients
People with clinical encounters
Subgroup of people with depression
In extreme cases, two individuals can meet the criteria for a diagnosis of MDD w/out sharing any
singly symptom
No clear cut line between sadness and depression
Depression as a global health crisis
No conclusion on what it is, and how it should optimally be treated
Critics question the application of the concept as it was developed in western societies
Some question conceptualising it as a biological disorder
Leads to a promotion of the pharmaceutical industry
Section 1: What is depression?
Current diagnostic approaches
WHO's 11th revision of its classification of diseases conceptualises depressions a syndrome (i.e., a
clinically recognisable set of reported experiences (symptoms) and observed behaviors (signs)
associated with distress and interference w/ personal functions
For a diagnoses at least five / ten symptoms have to present for most of the day, for at least 2 weeks
The presence of either the first or the second symptom or sign is mandatory
The disturbance should result in substantial functional impairment (i.e, functioning is only maintained
through additional effort)
It should not be a reflection of a different mental illness, should not be due to a drug and should not be
better explained by bereavement
3.4 Affective Disorders Literature 2
, Hopelessness about the future, the only symptom included in the ICD-11 but not in the DSMs,
performed more strongly than about half ot eh DSM symptoms in differentiating those with depression
The DSM hasn't changed its symbols since DSM3
Continuous or categorical classification of depression and the question of severity
More controversial than the list of symbols has been the number of symptoms required for diagnosis (at
least five, one of which must be either depressed mood or diminished interest or pleasure)
Sub-threshold depression (i.e., conditions characterised by the presence of less than 5 symptoms)
didn't differ from diagnosable depression w/ respect to many variables;
The exception is 'nuclear depressive syndrome' (melancholic depression subtype) which has a
higher suicide prevalence and a more vegetative symptomatology
i.e., melancholia as the most severe manifestation of depression
The threshold issue
Even if we assume that depression is continous the problem maintains
Lowering the threshold for diagnosing depression could reinforce medicalisation of normal sorrow,
driving inappropriate and unnecessary treatment
The way to solve this was to adopt at least one core depressive symptom
i.e., either (1) depressed mood; (2) loss of interest or pleasure), most of the time for at least 2
weeks
There is no clear line, even in clinical research in regards to how one should categorize sub-thresold
depression
The use of a measurement instrument - such as the PHQ9(Patient Health Questionnaire), based
on DSM crit has been proposed as a practical approach for addressing the question of the
threshold for sub-syndromal depression and the assessment of severity for depression
3.4 Affective Disorders Literature 3
, PHQ9 is the most widely used instrument for assessing depression
Scores can be interpreted as a continous measure of severity or categorised into degrees of
severity
The questionnaires typically assume equal weight of each symptom in determining depression
Yet, the network perspective on psychopathology, which understands mental disorders as
complex networks of interacting symptoms, suggests that the various symptoms might not have the
same weight in determining the severity of depression
“Depression sum-scored don't add up."
The 'complicated' or 'uncomplicated' status of depression predicted the severity of depression than
standard number-of-symptoms measures;
Complicated depression as characterised by at least one of the following:
Psychomotor retardation; psychotic symptoms; suicidal ideation; a sense of worthlessness
or guilt
Psychopathological oversimplification?
Some argue that the previous definition of depression into operational terms has oversimplified how we
understand depression
The idea is that the subjective experience of people w/depression is different from 'normal forms of
negative mood'
A study based on the network approach found sympathetic arousal (i.e., palpitations, tremors, blurred
vision, sweating) to be one of the most central symptoms in the depression network
Higher order dimensions and specifiers
Depression often co-exists with anxiety and bodily distress
These pathologies might require common therapeutic approaches
Has led some to propose a higher order category of common mental disorders
The DSM and ICD consider melancholic and psychotic features as specifiers rather than assuming that
these are distinc diagnostic entities; supported by evidence
The history of bipolar episodes should be investigated in everyone in a depressive episode
Bipolar depression is different in important aspects from MDD
The issue of mixed depression (i.e., a depressive syndrome accompanied by symptoms of thought,
motor or behavioral overactivation interpreted as contrapolar)
MDD with mixed features is defined in the DSM5 as a depressive episode w/ at least three tyupical
manic symptoms such as expansive mood, inflated self-esteem, or increased involvement in risky
activities
Age and gender
Until the early 2000s, depression was not recognised among preschool children
Has also been neglected among adolescents where moodiness is quite prevalent
In the DSM and ICD, the "only empathic difference in depression among children/adolescents
compared with adults is that "depressed mood can manifest as irritability
Adolescents are often not directly depressed, but rather manifest their feelings through age-
inappropriate behaviors and moodiness
Within the elderly population, similar to adolescents, depression is often ascribed to normal ageing, to
losses, or to physical illness
Depression as related more to somatic symptoms, anxiety, psychomotor retardation/agitation, and
psychotic features
3.4 Affective Disorders Literature 4
PROBLEM 1: DEPRESSION PT. 1
WHAT IS DEPRESSION? - OVERVIEW
Time for united action on depression: a Lancet-World Psychiatric Association
Commission (Herrman et al.)
Key messages and recommendation regarding depression
1. Depression is a common, but poorly recognized and understood health condition
Brings profound suffering to those both directly and indirectly affected by it
2. Depression is a heterogeneous entity experienced with various combinations of signs and symptoms,
severity levels, and longitudinal trajectories
Although usually classified as a binary disorder, depression has a diversity of clinical presentations,
severity levels, and longitudinal courses
Commonly overlaps with other conditions
3. Depression is universal, but culture and context matter
Anhedonia, depressed mood and fatigue are common, however there is considerable variability in
types and prevalence of symptoms among cultures
It's core features have been thoroughly described over centuries, which goes against the premise
that it is an exclusively modern problem
4. Prevention is essential to reducing the burden of depression globally
5. The experiences of depression and recovery are unique for each individual
Depression is the result of a set of factors, typically the interaction of proximal adversities with
genetic, social, environmental, and developmental risk and resilience factors
Requires at least mildly personalized treatments in order to work
6. Closing the care gap requires engagement of people with lived experience
Most people w/depression do not receive effective care due to a range of demand and supply
barriers
7. A formulation is needed to personalize care
Detection of depression on the basis of symptoms should be accompanied by a clinical review or
formulation, which takes into account individual circumstances
The complexity of the formulation can vary depending on the context of care and availability of
resources
8. A staged approach to care addresses the heterogenous nature of depression and its impacts on
individual, family, and community functioning
Offers a pragmatic tool to translate the heterogenous clinical nature of depression for management
Ensures the interventions are comprehensive but proportional to the individual severity
Facilitates a focus on intervening early in the course of the condition and graduating the intensity of
interventions
Looks at depression along a continuum
9. Collaborative deliver models are a cost-effective strategy to scale up depression interventions in
routine care
Collaborative care offers and evidence-based approach for the delivery of interventions by diverse
providers, tailored to the specific stage of the illness
3.4 Affective Disorders Literature 1
, 10. Increased investment with whole-of-society engagement is a priority to translate current knowledge into
practice and policy and to upgrade the science agenda
Introduction
Despite robust evidence of interventions many factors hamper the effectiveness of interventions
Most people affected by mental health problems do not receive appropriate interventions
Depression as an omnipresent experience that is difficult to narrow down to discrete frames as it involves
many deeply personal experiences
Diagnostic frames are useful, but we can't get overly attached to them as they can't encompass what it
is like to experience depression
Concept of depression refers to → condition that arises from multiple constellations of factors that operate
in various ways with widely different outcomes
Two expressions to describe the experience of depression
People with depression
Patients
People with clinical encounters
Subgroup of people with depression
In extreme cases, two individuals can meet the criteria for a diagnosis of MDD w/out sharing any
singly symptom
No clear cut line between sadness and depression
Depression as a global health crisis
No conclusion on what it is, and how it should optimally be treated
Critics question the application of the concept as it was developed in western societies
Some question conceptualising it as a biological disorder
Leads to a promotion of the pharmaceutical industry
Section 1: What is depression?
Current diagnostic approaches
WHO's 11th revision of its classification of diseases conceptualises depressions a syndrome (i.e., a
clinically recognisable set of reported experiences (symptoms) and observed behaviors (signs)
associated with distress and interference w/ personal functions
For a diagnoses at least five / ten symptoms have to present for most of the day, for at least 2 weeks
The presence of either the first or the second symptom or sign is mandatory
The disturbance should result in substantial functional impairment (i.e, functioning is only maintained
through additional effort)
It should not be a reflection of a different mental illness, should not be due to a drug and should not be
better explained by bereavement
3.4 Affective Disorders Literature 2
, Hopelessness about the future, the only symptom included in the ICD-11 but not in the DSMs,
performed more strongly than about half ot eh DSM symptoms in differentiating those with depression
The DSM hasn't changed its symbols since DSM3
Continuous or categorical classification of depression and the question of severity
More controversial than the list of symbols has been the number of symptoms required for diagnosis (at
least five, one of which must be either depressed mood or diminished interest or pleasure)
Sub-threshold depression (i.e., conditions characterised by the presence of less than 5 symptoms)
didn't differ from diagnosable depression w/ respect to many variables;
The exception is 'nuclear depressive syndrome' (melancholic depression subtype) which has a
higher suicide prevalence and a more vegetative symptomatology
i.e., melancholia as the most severe manifestation of depression
The threshold issue
Even if we assume that depression is continous the problem maintains
Lowering the threshold for diagnosing depression could reinforce medicalisation of normal sorrow,
driving inappropriate and unnecessary treatment
The way to solve this was to adopt at least one core depressive symptom
i.e., either (1) depressed mood; (2) loss of interest or pleasure), most of the time for at least 2
weeks
There is no clear line, even in clinical research in regards to how one should categorize sub-thresold
depression
The use of a measurement instrument - such as the PHQ9(Patient Health Questionnaire), based
on DSM crit has been proposed as a practical approach for addressing the question of the
threshold for sub-syndromal depression and the assessment of severity for depression
3.4 Affective Disorders Literature 3
, PHQ9 is the most widely used instrument for assessing depression
Scores can be interpreted as a continous measure of severity or categorised into degrees of
severity
The questionnaires typically assume equal weight of each symptom in determining depression
Yet, the network perspective on psychopathology, which understands mental disorders as
complex networks of interacting symptoms, suggests that the various symptoms might not have the
same weight in determining the severity of depression
“Depression sum-scored don't add up."
The 'complicated' or 'uncomplicated' status of depression predicted the severity of depression than
standard number-of-symptoms measures;
Complicated depression as characterised by at least one of the following:
Psychomotor retardation; psychotic symptoms; suicidal ideation; a sense of worthlessness
or guilt
Psychopathological oversimplification?
Some argue that the previous definition of depression into operational terms has oversimplified how we
understand depression
The idea is that the subjective experience of people w/depression is different from 'normal forms of
negative mood'
A study based on the network approach found sympathetic arousal (i.e., palpitations, tremors, blurred
vision, sweating) to be one of the most central symptoms in the depression network
Higher order dimensions and specifiers
Depression often co-exists with anxiety and bodily distress
These pathologies might require common therapeutic approaches
Has led some to propose a higher order category of common mental disorders
The DSM and ICD consider melancholic and psychotic features as specifiers rather than assuming that
these are distinc diagnostic entities; supported by evidence
The history of bipolar episodes should be investigated in everyone in a depressive episode
Bipolar depression is different in important aspects from MDD
The issue of mixed depression (i.e., a depressive syndrome accompanied by symptoms of thought,
motor or behavioral overactivation interpreted as contrapolar)
MDD with mixed features is defined in the DSM5 as a depressive episode w/ at least three tyupical
manic symptoms such as expansive mood, inflated self-esteem, or increased involvement in risky
activities
Age and gender
Until the early 2000s, depression was not recognised among preschool children
Has also been neglected among adolescents where moodiness is quite prevalent
In the DSM and ICD, the "only empathic difference in depression among children/adolescents
compared with adults is that "depressed mood can manifest as irritability
Adolescents are often not directly depressed, but rather manifest their feelings through age-
inappropriate behaviors and moodiness
Within the elderly population, similar to adolescents, depression is often ascribed to normal ageing, to
losses, or to physical illness
Depression as related more to somatic symptoms, anxiety, psychomotor retardation/agitation, and
psychotic features
3.4 Affective Disorders Literature 4
