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What differs among them are aspects of duration, timing, or presumed etiology.
Depressive disorders according to DSM V can be classified into:
– Disruptive mood dysregulation disorder
– Major depressive disorder
– Persistent depressive disorder (dysthymia)
– Premenstrual dysphoric disorder
– Substance and medication-induced depressive disorder
– Depressive disorder secondary to other medical conditions
– Other specified and unspecified
disorder characterized by mood disturbance is usually accompanied by
abnormalities in thinking and perception arising from mood disturbance.
- Major depressive disorder
- Bipolar I disorder
This is the presence of depressed mood or loss of interest in pleasure
with four or more of the following symptoms:-
1. Feeling of worthlessness or guilt
2. Impaired concentration
3. Loss of energy or fatigue
4. Suicidal thoughts
5. Loss or increase of appetite and weight
6. Insomnia or excessive sleep.
7. Psychomotor retardation or agitation.
The above symptoms are required to be present for at least 2 weeks.
Major depression may be present with or without psychotic features like delusions, hallucinations, or bizarre behavior.
Sleep impairment may involve initial insomnia, middle insomnia, or terminal insomnia.
Suicidal ideation may range from passive ideas e,g wishing one was death to active plans on how to kill oneself.
features are most often mood-congruent. i.e the content of delusion or
hallucination reflects depression.E.G a mood-congruent delusion might be
the belief that one has committed a terrible crime or sin.
A mood-congruent hallucination might be a voice that tells one to die or that says you have failed life.
The lifetime risk of developing MDD is 15% overall.
It is more common in women than men in a ratio of 2:1
The range of onset ranges from childhood to old age. The mean age is 4oyrs
Recurrence is common.50% of people who have one episode of MDD will have one or more additional episodes.
Depression results from the low level of mono-amines specifically serotonin and norepinephrine.
The exact cause is unknown however some of the implicated factors include:-
the incidence of MDD is higher among relatives of individuals with the
disorder than among the general population. 50% of the people with MDD
have a first-degree relative with a mood disorder.
Biochemical factors: The level of mono-amines Serotonin and Norepinephrine are reduced in individuals with major depressive illness
Cognitive factors; narrow negative view of self, the environment, and future
Psychosocial factors like unemployment, loss of loved one, stress,
Predisposing factors to major depressive disorder
1. Family history of depression
2. Gender: women are twice likely to get depression as men
3. Health conditions like cancer, heart disease, and thyroid disorder
4. Violence, physical or emotional abuse such as rape
7. Changes and stressful events such as relationship breakups, starting of a new job.
Somatic symptoms of depression
Significant decrease in appetite and weight
Early morning awakening at least 2 or more hours before usual time of waking up.
Lack of interest and lack of reactivity to pleasurable stimuli.
Psychomotor agitation or retardation
Forms of depression
depression (exogenous depression) : state of depression that people
experience in response to external stressor. Caused in reaction to
external event or circumstance. e.g death of a family member, divorce or
Endogenous depression: depression that has
no obvious cause. Believed to be originating from within an individual.
Linked with genetic nature of individual
Antidepressants : SSRIs , TCAs , MOAi,
Physical therapies: ECT indicated for severe depression with suicidal risk
Psychotherapy: Emphasizes helping patients gain insight into the cause of their depression
Cognitive therapy: aims at correcting the depressive negative cognitions like hopelessness and pessimistic ideas
Supportive psychotherapy: various techniques are employed to support the patient. They are reassurance, occupational psychotherapy, relaxation
Group Therapy: sharing experiences to improve the expression of their feelings
Behavior therapy: includes social skill training.
Family therapy: used to reduce or modify stressors.
treatment in severe depression is a TCA unless it is contra-indicated.
The main contra-indications are coexisting cardiac disease and
intolerance to anticholinergic side effects like urine retention
main alternatives to TCAs are the SSRIs which do not have side effects,
are not sedating, and are safe in overdose. The main s/e are nausea,
diarrhea and agitation
If the patient does not respond to 6
weeks of treatment on a therapeutic dose of TCA or an SSRI, consider
increasing the dose of current medication or changing to anti-depressant
Anti-psychotics should be used if the depression is accompanied by a psychotic episode
is indicated in the management of resistant depression and where
anti-depressants are contra-indicated or when patients' life may be at
risk from suicide or dehydration arising from the refusal to eat or
Anti-depressants should be continued for a minimum of 6 months after the resolution of an acute episode
Encourage the patient to express emotions. Provide the patient opportunity to cry out and ventilate their anger.
Assess if there is any suicidal tendency. Take safety measures and keep vigil if the patient has suicidal ideas.
Administer prescribed antidepressants in time and monitor food intake.
non-intellectual activities e.g cleaning physical exercises provide
safe and effective methods of discharging vent up tension.
Promote sleep and food intake. Most patients have insomnia and lack appetite
Keep a strict record of sleeping patterns. Discourage sleep during the day to promote more restful sleep at night.
Promote or interact with the patient and focus and not far in future.
Provide health education to patient and relatives regarding disease and drugs.
Health education shared on drugs
Take medications regularly and the right dose.
Teach the patient when therapeutic effects will be seen.At least 2 to 3 weeks must elapse before he feels better
Inform the patient of the side effects of antidepressants
Teach the patient to avoid alcohol as it causes drug interaction and may cause harm.
Not to stop medication without medical advice
Health messages shared to family members
Advise the family to watch for any suicidal ideas or gestures and inform the clinician immediately.
To give adequate support and encouragement to the patient
To give accept the patient as he is and give him hope and care
To give medication regularly as prescribed.
To provide the correct history to a clinician
A disorder characterized by episodes of mania and depression.
A condition characterized by excessive happiness with inflated self-esteem (grandiosity)
is quite common for a patient in a manic state to believe that he or
she is special. A person may believe that he is on a special mission
Presenting features of mania
Expansive or irritable mood. The person feels extremely high.
or she may describe the experience as feeling on top of the world. The
patient may shift from highly elated mood to being angry and irritable
if they perceive to have been obstructed.
Hyperactivity or psychomotor agitation
Delusions of grandiosity.
Flight of ideas.
Easy distractibility. respond to multiple unimportant stimuli
Dress on bright colors often that do not match
Excessive make-up and jewelry
Marked impairment in occupational functioning, social activities or relationships
Hallucinations most commonly auditory
Genetic factors: Mania run through families.
Biochemical factors: Mania is considered to be due to excessive biogenic amines (excess norepinephrine and serotonin)
Psychological factors (stress commonly precedes the 1st episode of both major depression and mania.
stabilizers: drugs with mood stabilizers properties e.g sodium
valproate, carbamazepine, lamotrigine, and lithium should be instituted
early in treatment
❖Antipsychotic drugs such as olanzapine,
haloperidol or chlorpromazine may be co-administered during the initial
period to control behavior and psychosis.
particularly lorazepam may be used to treat mania. They complement
antipsychotic dose given in 24hrs reducing EPSEs
Avoid any verbal confrontation as the patient can be easily irritated.
Maintain a therapeutic calm environment. Remove any external stimulation such as noise and lights where possible.
Observe the patient for fluctuation of mood. Mood fluctuates from excessive happiness to being irritable.
Administer prescribed mood stabilizers and antipsychotics to reduce restlessness and sleeplessness caused by overactivity.
Provide the patient with consistent limits on dressing and activities
Observe the patient for any destructive activities that may result in injury.
Engage the patient in active games, ward occupation and creative work to channel his energy
the patient take food for physiological needs. The patient is usually
too busy to eat hence may loose weight and dehydration may occur. Meals
and fluids should be given under supervision.
Disruptive Mood Dysregulation Disorder
Characterized by chronic severe and persistent irritability and angry
mood manifested by frequent (3-4 times a week) temper outbursts verbally
or behavioral in response to frustration.
⚫ These are developmentally inappropriate and occur over at least 1 year both at home and school.
⚫ Associated with familial anxiety disorder and temperamental development.
⚫ There is marked disruption in the child’s family and peer relationships as well as school performance.
⚫ Suicidal ideation and attempts may be present.
Premenstrual Dysphoric Disorder
⚫ Significant affective symptoms that emerge in the week prior to menses and quickly disappear with the onset of menses
At least five symptoms which include marked affective lability,
depressed mood, irritability, or tension with one or more symptoms of a
major depressive episode.
⚫ Duration: Present in all menstrual cycles in the past year and documented prospectively for two menstrual cycles.
⚫ It causes clinically significant distress or impairment.
⚫ Treatment: SSRI’s, CBT