Summary: 3.4 A&ective Disorders
,Depression I
Þ Definition of Depression - 2 main sub-categories:
(1) major depressive disorder (MDD)
(2) dysthymia - persistent or chronic form of mild depression – less intense and last longer
Þ global and regional estimates of prevalence
o proportion of global population with depression (2015): 4.4%
o total number of people living with depression: 322 million
o depression – most frequently diagnosed in psychiatric practice
o vary by age
• peaks in older adulthood
Þ estimates of health loss
o depressive disorders led to a global total of over
50 million Years Lived with Disability
• more than 80% of this non-fatal disease burden occurred in low- and middle-income
countries
• African Region – highest
o depressive disorders – ranked as the single largest contributor to non-fatal health loss
CLINICAL CHARACTERISATION OF THE ADULT PATIENT WITH DEPRESSION
Domains
Symptom Profile
Þ DSM-5 and ICD-11 symptoms: almost identical
o depressed mood
o markedly diminished interest or pleasure in activities
o reduced ability to think or concentrate, or indecisiveness
o feelings of worthlessness, or excessive or inappropriate guilt
o recurrent thoughts of death, or suicidal ideation, or suicide attempts or plans
o insomnia or hypersomnia
o significant change in appetite or weight
o psychomotor agitation or retardation
o fatigue or loss of energy
Þ ICD-11: includes hopelessness about the future
o outperformed about half of the DSM-5 symptoms in differentiating depressed from
non-depressed subjects
Þ core symptoms of depression: sympathetic arousal (palpitations, tremors, sweating) AND
anxiety
Þ model of depression, 3 clusters
o core emotional symptoms antidepressant medication in general has been found to be more
o sleep symptoms effective in treating those symptoms
, o “atypical” symptoms: including psychomotor agitation, psychomotor slowing, suicidal
ideation, reduced libido, hypochondriasis
Þ overall: some evidence that supports the notion that the symptom profile (beyond diagnosis
of depression) may have value in predicting the response to specific antidepressants or to
antidepressant medication vs specific psychotherapies
o assessment of suicidality: important
o all patients presenting with depression should be screened for bipolar disorder
Clinical Subtypes
Þ 2 core subtypes:
o melancholic/endogenous/vital/autonomous
• arise from biological perturbations
o non-melancholic/ reactive/neurotic/situational
• linked to situational factors
o the distinction can be assisted by the Sydney melancholia prototype index
Þ DSM-5: “with melancholic features” by the presence of:
o either loss of pleasure in (almost) all activities OR lack of reactivity to usually
pleasurable stimuli
o at least 3 of the following
• distinct quality of depressed mood
• worsening of the depression in the morning
• early-morning awakening
• marked psychomotor agitation or retardation
• significant anorexia or weight loss
• excessive or inappropriate guilt
Þ psychotic depression – another widely accepted subtype
o defined by the presence of delusions or hallucinations during the depressive episode,
and the lack of persistence of psychotic symptoms outside of the period of depression
o psychotic features in depressed individuals:
• associated with increased suicidality (especially during acute phases), increased
mortality from physical causes, and poorer outcome
o assessed with semi-structured interviews
o recommend combined antidepressant and antipsychotic medication or
electroconvulsive therapy as first-line treatment for psychotic depression
Þ mixed depression
o the DSM-5 requires the presence of at least 3 manic/hypomanic symptoms out of 7
• elevated, expansive mood; inflated self-esteem or grandiosity; more talkative than
usual or pressure to keep talking; flight of ideas or racing thoughts; increase in
energy or goal-directed activity; increased involvement in risky activities; and
decreased need for sleep
o presence of (hypo-)manic symptoms during a depressive episode is associated with
• higher rate of anxiety and substance use disorders
• increased suicidality
• greater impairment in functioning
• more frequent family history of bipolar disorder
• poorer response to treatment
o most used measure: the Young Mania Rating Scale
Þ anxious depression
o presence of at least 2/5 symptoms:
, • feeling keyed up or tense, feeling unusually restless, difficulty concentrating
because of worry, fear that something awful may happen, feeling that the individual
might lose control of himself
o w/ anxious depression:
• higher levels of suicidal ideation
• poorer functioning
• poorer health-related quality of life
• greater chronicity
Þ seasonal depression: based on the lifetime pattern of depressive episodes
o most common pattern: autumn/winter onset and spring/summer resolution
o characteristic symptoms: hypersomnia, hyperphagia, carbohydrate craving
o bright light therapy – effective
Severity
Þ severity of depression – associated with health-related quality of life, functional
impairment, suicidality, longitudinal course, and response to treatment
Þ DSM-5: depression is classified as mild, moderate, or severe
o classification is based on the number of symptoms present, the level of distress caused
by the intensity of the symptoms, and the degree of impairment in social and
occupational functioning
• severe: number of symptoms is substantially in excess of that required to make the
diagnosis, the intensity of the symptoms is seriously distressing and unmanageable,
and the symptoms markedly interfere with social and occupational functioning
o consider the degree of impairment as co-equal to symptom level
o depression severity: an important consideration in treatment decision-making
• no agreement on how this severity should be assessed (-)
Neurocognition
Þ cognitive deficits: core dimension of the depressive syndrome
o have been identified in both first- and multiple-episode patient populations
o may be progressive in patients with depression, especially in the sub-domain of
learning/memory
o presence of cognitive deficits: implications for the formulation of the management plan
Þ neurocognition:
o executive functions
• planning, initiation, sequencing, monitoring, inhibition of thoughts, moods,
behaviour
o attention/concentration
o learning/memory
o processing speed
Functioning & Quality of Life (QOL)
Þ DSM-5: require that the symptoms “cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning
o difficult for the clinician to assess those
Þ QOL – confusing concept
o objective QOL: refers to a functionalist approach: the ability to perform roles that are
considered normal for people, aiming at an optimal level of functioning defined
externally by society
o subjective QOL: refers to a needs-based approach: the ability and capacity to satisfy
one’s needs, which involves a personal cognitive-emotional appraisal and mediates
,Depression I
Þ Definition of Depression - 2 main sub-categories:
(1) major depressive disorder (MDD)
(2) dysthymia - persistent or chronic form of mild depression – less intense and last longer
Þ global and regional estimates of prevalence
o proportion of global population with depression (2015): 4.4%
o total number of people living with depression: 322 million
o depression – most frequently diagnosed in psychiatric practice
o vary by age
• peaks in older adulthood
Þ estimates of health loss
o depressive disorders led to a global total of over
50 million Years Lived with Disability
• more than 80% of this non-fatal disease burden occurred in low- and middle-income
countries
• African Region – highest
o depressive disorders – ranked as the single largest contributor to non-fatal health loss
CLINICAL CHARACTERISATION OF THE ADULT PATIENT WITH DEPRESSION
Domains
Symptom Profile
Þ DSM-5 and ICD-11 symptoms: almost identical
o depressed mood
o markedly diminished interest or pleasure in activities
o reduced ability to think or concentrate, or indecisiveness
o feelings of worthlessness, or excessive or inappropriate guilt
o recurrent thoughts of death, or suicidal ideation, or suicide attempts or plans
o insomnia or hypersomnia
o significant change in appetite or weight
o psychomotor agitation or retardation
o fatigue or loss of energy
Þ ICD-11: includes hopelessness about the future
o outperformed about half of the DSM-5 symptoms in differentiating depressed from
non-depressed subjects
Þ core symptoms of depression: sympathetic arousal (palpitations, tremors, sweating) AND
anxiety
Þ model of depression, 3 clusters
o core emotional symptoms antidepressant medication in general has been found to be more
o sleep symptoms effective in treating those symptoms
, o “atypical” symptoms: including psychomotor agitation, psychomotor slowing, suicidal
ideation, reduced libido, hypochondriasis
Þ overall: some evidence that supports the notion that the symptom profile (beyond diagnosis
of depression) may have value in predicting the response to specific antidepressants or to
antidepressant medication vs specific psychotherapies
o assessment of suicidality: important
o all patients presenting with depression should be screened for bipolar disorder
Clinical Subtypes
Þ 2 core subtypes:
o melancholic/endogenous/vital/autonomous
• arise from biological perturbations
o non-melancholic/ reactive/neurotic/situational
• linked to situational factors
o the distinction can be assisted by the Sydney melancholia prototype index
Þ DSM-5: “with melancholic features” by the presence of:
o either loss of pleasure in (almost) all activities OR lack of reactivity to usually
pleasurable stimuli
o at least 3 of the following
• distinct quality of depressed mood
• worsening of the depression in the morning
• early-morning awakening
• marked psychomotor agitation or retardation
• significant anorexia or weight loss
• excessive or inappropriate guilt
Þ psychotic depression – another widely accepted subtype
o defined by the presence of delusions or hallucinations during the depressive episode,
and the lack of persistence of psychotic symptoms outside of the period of depression
o psychotic features in depressed individuals:
• associated with increased suicidality (especially during acute phases), increased
mortality from physical causes, and poorer outcome
o assessed with semi-structured interviews
o recommend combined antidepressant and antipsychotic medication or
electroconvulsive therapy as first-line treatment for psychotic depression
Þ mixed depression
o the DSM-5 requires the presence of at least 3 manic/hypomanic symptoms out of 7
• elevated, expansive mood; inflated self-esteem or grandiosity; more talkative than
usual or pressure to keep talking; flight of ideas or racing thoughts; increase in
energy or goal-directed activity; increased involvement in risky activities; and
decreased need for sleep
o presence of (hypo-)manic symptoms during a depressive episode is associated with
• higher rate of anxiety and substance use disorders
• increased suicidality
• greater impairment in functioning
• more frequent family history of bipolar disorder
• poorer response to treatment
o most used measure: the Young Mania Rating Scale
Þ anxious depression
o presence of at least 2/5 symptoms:
, • feeling keyed up or tense, feeling unusually restless, difficulty concentrating
because of worry, fear that something awful may happen, feeling that the individual
might lose control of himself
o w/ anxious depression:
• higher levels of suicidal ideation
• poorer functioning
• poorer health-related quality of life
• greater chronicity
Þ seasonal depression: based on the lifetime pattern of depressive episodes
o most common pattern: autumn/winter onset and spring/summer resolution
o characteristic symptoms: hypersomnia, hyperphagia, carbohydrate craving
o bright light therapy – effective
Severity
Þ severity of depression – associated with health-related quality of life, functional
impairment, suicidality, longitudinal course, and response to treatment
Þ DSM-5: depression is classified as mild, moderate, or severe
o classification is based on the number of symptoms present, the level of distress caused
by the intensity of the symptoms, and the degree of impairment in social and
occupational functioning
• severe: number of symptoms is substantially in excess of that required to make the
diagnosis, the intensity of the symptoms is seriously distressing and unmanageable,
and the symptoms markedly interfere with social and occupational functioning
o consider the degree of impairment as co-equal to symptom level
o depression severity: an important consideration in treatment decision-making
• no agreement on how this severity should be assessed (-)
Neurocognition
Þ cognitive deficits: core dimension of the depressive syndrome
o have been identified in both first- and multiple-episode patient populations
o may be progressive in patients with depression, especially in the sub-domain of
learning/memory
o presence of cognitive deficits: implications for the formulation of the management plan
Þ neurocognition:
o executive functions
• planning, initiation, sequencing, monitoring, inhibition of thoughts, moods,
behaviour
o attention/concentration
o learning/memory
o processing speed
Functioning & Quality of Life (QOL)
Þ DSM-5: require that the symptoms “cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning
o difficult for the clinician to assess those
Þ QOL – confusing concept
o objective QOL: refers to a functionalist approach: the ability to perform roles that are
considered normal for people, aiming at an optimal level of functioning defined
externally by society
o subjective QOL: refers to a needs-based approach: the ability and capacity to satisfy
one’s needs, which involves a personal cognitive-emotional appraisal and mediates
