Sneak peek 2 of integrated handbook of volume 2

Dear friends,

   Here we are launching sneak peek of volume 2.book is due to release by 31 January tentatively.One IMNCI booklet by WHO and supplement question bank with many new questions scenario based useful for DNB theory exams  is free with this volume.Last few days remaining to book at a special prize volume 2 & 3.So make most of it.Good day.

                                                   Depression

·         Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest.

·         It is also called major depressive disorder (MDD) or clinical depression.

·         It affects how a person feels, thinks and behave and can lead to a variety of emotional and physical problems. 

Epidemiology

Lifetime prevalence

·         16.4% MDD

·         2.5% Dysthymia

Etiology of Mood Disorders:

·         Neurobiological Factors

·         Genetic factors

·         Heritability estimates 93% Bipolar Disorder &37% MDD

·         Heritability estimates higher for women than men

·         Neurotransmitters

§  Low levels of norepinephrine, dopamine, and serotonin

·         Neuroendocrine theories

§  Over activity of HPA axis triggers release of cortisol - stress hormone.

§  Findings that link depression to high cortisol levels are Cushing’s syndrome which causes over secretion of cortisol.

§  Symptoms include those of depression.

§  Injecting cortisol in animals produce depressive symptoms.

§  Dexamethasone suppression test.

§  Lack of cortisol suppression in people with history of depression.

Psychological theories

Freud’s theory

·         Oral fixation leads to excessive dependency, depression, anger towards loved ones who reject us is turned inward.

·         Affect

·         High negative affect

·         Low positive affect

In response to positive stimuli, depressed individuals experience:

·         Fewer positive facial expressions

·         Report less pleasant emotion

·         Show less motivation

·         Demonstrate less psychophysiological activity

·         Neuroticism

·         Tendency to react with higher levels of negative affect

·         Predicts onset of depression

·         Extraversion

·         Associated with high levels of positive affect

·         Low extraversion does not always precede depression

Cognitive theories

Beck’s theory: Negative triad

Negative view of:

·         Self, world, future

·         Negative schemata

·         Underlying tendency to see the world negatively

·         Negative schemata cause cognitive biases

·         Tendency to process information in negative ways

DSM 5 criteria

·         5 or more symptoms present in same 2-week period, where at least one symptom is (1) depressed mood or(2) loss of interest or pleasure.  Depressed mood most of the day nearly every day.

·         In children/adolescents can be irritable mood

·         Diminished interest/pleasure in all or almost all activities most of the day nearly every day

·         Weight loss, weight gain, decrease/increase in appetite

·         In children, failure to make expected weight gain

·         Insomnia/hypersomnia

·         Psychomotor agitation/retardation

·         Fatigue or loss of energy and worthlessness or excessive or inappropriate guilt

·         Diminished ability to think or concentrate, or indecisiveness.

·         Recurrent thoughts of death, recurrent suicidal ideation, suicide attempts, or suicide plans

Clinical features

·         Motivation- Apathy, loss of energy and interest:  things seem pointless, hopeless

·         Emotional- Low mood, emptiness, anger or resentment, anxiety, shame, guilt

·         Cognitive - Poor concentration, negative ideas about the self, the world and the future. 

·         Behaviour - Lowered activity, social withdrawal, agitation or retardation. 

·         Biological - Sleep disturbance, loss of appetite, loss of weight, changes in circadian rhythms, hormones and brain chemicals. 

·         Lack of energy

·         Loss of appetite

·         Weight loss or gain

·         Unexplained headache or backache

·         Stomachaches, indigestion or changes in bowelhabits.

Objective Rating Scales for Depression

·         The Zung Self-Rating Depression Scale is a 20-item report scale.

·         The Raskin Depression Scale

·         The Hamilton Rating Scale for Depression (HAM-D) is a widely used depression scale with up to 24 items.

Prognosis

·         Major depressive disorder tends to be chronic.

·         Patients who have been hospitalized for a first episode ofmajor depressive disorder have about a 50 percent chance of recovering in the first year.

·         About 25 percent of patients experience a recurrence of major depressive disorder in the first 6 months after release from a hospital, about 30 to 50 percent in the following 2 years and about 50 to 75 percent in 5 years.

Treatment

1. Class of antidepressant drugs used for depression

·         SSRI-selective serotonin reuptake inhibitors: Fluoxetine, Escitalopram, Sertraline, Paroxetine

·         TCA- tricyclic antidepressants:Amitryptilline, Imipramine, Clomipramine  

·         MAO inhibitors

·         SNRI- serotonin norepinephrine reuptake inhibitors:Venlafaxine, Duloxetine.

·         Others:Mirtazapine, Bupropion, Trazodone, Vilazodone

2. Electroconvulsive therapy (ECT)

Indications

·         non-responders Severe depression with high risk of suicide

·         Depression with psychotic features, melancholic features.