# Book - At Atlas of Depression David S Baldwin & Jon Birtwistle, 2002 # Chapter 2 - Epidemiology - Approximately 15% of the general population report depressive symptoms, with 10% of primary care consultations due to depressive disorders1. - Twice as prevalent in women as in men. - Approximately 15% of the general population report depressive symptoms, with 10% of primary care consultations being due to depressive disorders1. - 1. OrmelJ,TiemensB.Depressioninprimarycare.InHonigA, van Praag HM, eds. Depression: Neurobiological, Psychopathological and Therapeutic Advances. Chichester, UK: John Wiley, 1997 - There is some evidence that women develop more complex and severe clinical pictures, and probably a more troublesome course3. - 1. AngstJ.Epidemiologyofdepression.InHonigA,vanPraag HM, eds. Depression: Neurobiological, Psychopathological and Therapeutic Advances. Chichester, UK: John Wiley, 1997 - Depression and [[Anxiety]] usually occur together. 2/3 of those have a lifetime history of another psychiatric disorder - Depression and anxiety usually occur together, both in community and clinical samples. Approximately two- thirds of those with a lifetime history of major depression have a lifetime history of another psychiatric disorder, and an even higher proportion of those with anxiety have multiple previous disorders. # Chapter 4 - Descriptions of the depressive disorders - Unipolar and Bipolar Depression - Major Depressive Episode - Dysthymia (Dysthymic Disorder) - Recurrent Brief Depression - Mixed anxiety and depressive disorder - Seasonal affective Disorder - Postpartum Depression - Bipolar Affect Disorder (Manic-Depressive psychosis) - Depression and Anxiety after Bereavement # Chapter 6 - Suicide [[Suicide]] # Chapter 7 - Causes of Depression ^6091a9 From combination of biopsychosocial factors over a period of time. In most patients, depressive episodes arise from the combination of familial, biological, psychologic and social factors, operating over time and progressively increasing the risk of developing a depressive disorder. Depressed mood also occurs in certain physical illnesses (see Figure 7.3) and as a part of many different psychi- atric syndromes, e.g. anxiety disorders, alcohol abuse, substance abuse and eating disorders (see Tables 1 and 2 and Figure 7.4). ![[Screenshot 2023-07-15 at 11.37.52 AM.png]] ## Genetic Factors ^45fd69 - First-degree relatives with depression have increased risk. - Potential genetic markers for affective disorders have been localized to chromosomes X, 4, 5, 11, 18 and 21. - Some of these sites have been linked to the neurobiology of depression: for example, two of the putative markers on the long arm of chromosome 5 contain candidate genes contributing to the receptors for norepinephrine, dopamine, g-amino butyric acid and glutamate1. ## Neurotransmitter Disturbances - Abnormalities in the level or function of the serotonin (5-hydroxytryptamine, 5-HT), norepinephrine and dopamine neurotransmitters acting on central nervous system neurons may be important in the pathophysiology of depression, although this evidence is inconclusive. - Patients with major depression appear to have abnormal serotonergic neurotransmission - Depression is also associated with increased 24-h adrenocorticotropic hormone (ACTH) levels, as well as elevated urinary and plasma cortisol levels. - Recent research indicates that depression is associated with enlargement of the adrenal glands, which shrink in size following adequate treatment. Some of the changes in brain 5-HT function seen in depressed patients may themselves result from hypersecretion of cortisol5. - Dopaminergic dysfunction has been reported in psychotic and bipolar depression, seasonal affective dis- order and depression associated with Parkinson’s disease. - Manic episodes may be associated with over- activity in dopamine pathways within the brain, as mania can be provoked by dopamine-releasing psycho- stimulants, such as cocaine and amphetamine. ### Structural and Functional Abnormalities of the brain - There have been no adequate controlled post-mortem studies of brain structure in bipolar illness. However, these abnormalities are not reported consistently8, and are less marked than those seen in many patients with schizophrenia. ## Psychosocial Factors - Low self-esteem, an obsessional personality, the experience of adversity in childhood and maladaptive negative patterns of thinking about oneself and others are all recognised psychologic ‘risk factors for depression. Other factors include excessive undesirable recent life events, usually involving loss (such as bereavement, divorce and redundancy), and persisting major difficulties, including being a lone parent, overcrowding, pro- longed unemployment, poverty and lack of social support or intimacy. - Psychosocial factors, particularly family dynamics, are undoubtedly important in influencing the course of bipolar illness once established. However, their role in causing the condition to appear is unclear. # Chapter 8 - The need for long-term treatment of depression - The focus of treatment should be as much on long-term management as on short-term relief of symptoms. - Common Treatment Model - Initial acute treatment results in a significant reduction of depressive symptoms (response), - followed by progression to the premorbid state, with absence of symptoms (remission). Stable remission for 4–6 months constitutes a recovery from depression. - A worsening of symptoms or return of major depression is called relapse if it occurs before recovery has been achieved, and recurrence if it occurs later. Relapses are assumed to represent inadequate treatment of the index depressive episode, whereas recurrence represents a new episode of illness. Three Phases of Treatment - Acute treatment lasts until remission, - continuation of treatment from remission to recovery - and maintenance (or prophylaxis) from recovery onwards. Over 1/3 of patients with depression experience relapse in first year after remission - over one-third of patients with major depression experience a relapse of depression in the first year after remission of symptoms - Most relapses occur in the first 4 months in younger adults, but in elderly patients the risk of relapse extends more steadily over 12 months2. # Chapter 9 Antidepressant Drugs ![[Screenshot 2023-07-15 at 11.48.56 AM.png]]![[Screenshot 2023-07-15 at 11.49.07 AM.png]] # Chapter 10 - Physical Treatments for Depression ## ECT - Electroconvulsive therapy (ECT) involves the induction of a brief seizure induced by passing an electrical current across a patient’s brain following the administration of a general anesthetic and a muscle relaxant. ECT has a potent antidepressant effect, which has an earlier onset of action than antidepressant drugs. It has been found to be effective in the treatment of a number of psychiatric and neurologic conditions, including mood disorders (particularly psychotic depression), psychosis and Parkinson’s disease. It is particularly effective when there is abnormal motor activity, e.g. catatonia, stupor and parkinsonism. The main indications for the use of ECT include: - depressive stupor; - failure to eat or drink; - high risk of suicide; - depressive delusions; - marked psychomotor retardation; and - previous good response to ECT. ## Sleep Deprivation - There is a wide body of literature to indicate that sleep deprivation can sometimes improve the mood of depressed patients2. Sleep deprivation can be used in several ways, including total sleep deprivation (TSD), partial sleep deprivation (PSD), phase-advance therapy and selective rapid eye movement sleep deprivation. TSD involves the patient staying awake for up to 40 h starting from the morning before the night of sleep deprivation. In PSD, patients may sleep for 4 h and are then asked to wake up at around 01:00 to 02:00 and remain awake the rest of the night and the following day. The phase-advance approach involves changing the sleep pattern without sleep deprivation, e.g. patients go to bed at 18:00 and get up at 01:00. The antidepressant effect of sleep deprivation is not clearly understood - Interesting, we don't use this now ## Light Therapy Light treatment (phototherapy) is most closely associ- ated with the treatment of seasonal affective disorder. There are a number of devices used in light therapy, the most researched being the light box, with white light and an illumination of 10 000 lux ## Transcranial Magnetic Stimulation Rapid TMS (rTMS) involves passing a rapidly alternating electrical current through a small coil attached to the scalp, thereby inducing an electromagnetic pulse, which induces a change in the ionic flow of surrounding brain tissue. Several studies have found that rTMS of the left dorsolateral prefrontal area in healthy volunteers produced a feeling of sadness, while stimulation of the right dorsolateral prefrontal area produced a feeling of happiness5. However, in depressed patients, rTMS of the left dorsolateral prefrontal area produced significant improvement. # Chapter 11 Psychologic Therapies Cognitive–behavior therapy - In essence, depression is argued to result from cognitions and not mood and postulates that there are three maladaptive elements of depression: (1) a cognitive triad of recurrent negative views that directly shape how the person sees themselves (negative self-concept, e.g. worthless), the world (overestimation of demands, e.g. life is meaningless); and, the future (e.g. hopeless). - (2) irrational schemata based on the past and logical errors that pervade the assessment of oneself and life events; and - (3) a number of typical processing errors, through which perceptions of events are distorted. [[15 Cognitive Distortions in CBT]] Other counselling approaches