1 DEPRESSIVE DISORDER To feel unhappy or sad at the time of adversity is universal phenomenon.

Depression is often defined as morbid sadness or sadness which is both quantitatively and qualitatively distinct from the depression that normally accompanies bereavement or other loss. Depressive disorder is a form of mood disorder, usually episodic in nature, having the characteristic features affecting biological and psychological functioning of the individual. CLASSIFICATION: A) According to aetiology: 1) Reactive 2) Endogenous B) According to cause: Unipolar Bipolar C) According to symptomatology: Retarded depression Agitated depression Masked depression D) According to severity: Mild Moderate Severe CLINICAL FEATURES A) Psychological: Depressed / dysphoric mood Loss of interest Tearfulness Psychomotor retardation / agitation Low self-esteem Loss of self-confidence (worthlessness) Ideas of guilt Hopelessness Impaired concentration Inefficient thinking Fatigue, loss of energy Suicidal ideation / plan / attempt A) Biological: Sleep disturbance- early morning awakening Change of appetite Weight change Decreased libido Diurnal variation in mood- worse in morning Constipation

2 Amenorrhoea B) Other features: Anxiety features: -Worry -Headache/other pain -Hypochondriasis Psychotic features: -Hallucination

-Panic attack -Phobia / obsessional symptoms -Delusion

In some cases of depression, somatic symptoms may mask the underlying depressionMultiple vague somatic complaints GI symptoms- altered bowel habit CVS symptoms Genitourinary Headache / hotness in head Muscular pain Respiratory symptoms Exacerbation of pre-existing physical symptoms AETIOLOGY Predisposing factor o Genetic- Positive family history o Environment- Loss of mother before 11 years; Lack of confiding relationship; Unemployment. o Alcoholism and chronic physical illness. o Personality- Low self-esteem. Precipitating factor o Severe life events- bereavement, marital separation o Child birth o Physical illness- Bronchial carcinoma, MI, Influenza Perpetuating factor o Unresolved social stress- continued interpersonal conflict o Illness behavior- loss of role as worker or housewife. o Excessive alcohol consumption.

EPIDEMIOLOGY Age increases with age. More common in women than men. M:F= 1:2 More common in lower socioeconomic groups. Marital status- Depression is more common among divorced and separated persons than among married persons. DIAGNOSIS

3 Diagnosis is made based on history, MSE and physical examinations. Diagnostic Criteria: 5 or more of the following criteria, persisting for more than 2 weeksDepressed mood Loss of interest or pleasure in daily activities Appetite / Weight change ( > 5% weight change in a month) Insomnia / Hypersomnia Psychomotor retardation / agitation Fatigue / Loss of energy Worthlessness / Guilt Decreased concentration / Indecisiveness Suicidal ideation / Plan / Attempt MANAGEMENT A) Drugs: -Antidepressants (Tri-cyclic antidepressants, MAOI, SSRI) -Adjunctive drugs (e.g. Lithium, if no response to two different antidepressants) -ECT ( if life-threatening or non-responsive) Duration 6 months after clinical recovery. It decreases relapse. B) Psychological: -Supportive- listening, explaining nature of diseases. -Cognitive behavior therapy -Other indicated psychotherapies (couple, family, interpersonal therapies) C) Social: -Financial: eligible benefits, debt counseling -Employment: acquire or change the job -Housing: adequate, secure housing; safe, social neighbours -Family support PROGNOSIS: Almost 50%-85% had 2nd episode within 6 months. After treatment, 50% become mentally healthy, moderate impairment persists in 30%, 20% remains significantly impaired even after long follow-up. Organic Affective Disorders Diseases that may cause affective disorders by direct action on the brainA) NeurologicalCVD; Huntingtons chorea; Brain tumour; Multiple sclerosis; Alzheimers disease; Epilepsy; Parkinsons disease. B) Endocrine: Hypothyroidism; Addisons disease; Hyperthyroidism; Hyperparathyroidism; Cushings syndrome C) Infections: Glandular fever; Typhoid; Herpes simplex D) Connective tissue disease- SLE E) Malignant disease F) Drugs- Reserpine; Metyldopa; Phenothiazines; Corticosteroids; Oral contraceptives.