The following lecture has been approved for

University Undergraduate Students

This lecture may contain information, ideas, concepts and discursive anecdotes
that may be thought provoking and challenging
It is not intended for the content or delivery to cause offence
Any issues raised in the lecture may require the viewer to engage in further
thought, insight, reflection or critical evaluation

Depressive Illness

Dr. Craig Jackson

Senior Lecturer in Health Psychology
Faculty of Health
BCU
health.bcu.ac.uk/craigjackson

craig.jackson@bcu.ac.uk

The good physician

treats the disease,
but the great physician
treats the person.
William Osler

Traditional model of Disease Development

Pathogen

Modifiers
Lifestyle
Individual susceptibility

Disease (pathology)

Dominance of the biopsychosocial model

Mainstream in last 15 years

Hazard
Illness (well-being)

Psychosocial Factors
Attitudes
Behaviour
Quality of Life

Rise of the person as

a psychological
entity

Depressive Illness
Usually treatable
Common
Marked disability
Reduced survival
Increased costs
Depression may be
Coincidental association
Complication of physical illness (i.e. secondary depression)
Cause of / Exacerbation of somatic symptoms

Psychiatry in Pictures Steve Blundell

Digital Cry
Stapled Red

Depressive Illness
2% of population suffer from pure depression
(evenly distributed between mild, moderate, and severe)
Further 8% suffer from a mixture of anxiety and depression
Patients with symptoms not severe enough to qualify for diagnosis of either
anxiety or depression..... ???
Impaired working and social lives and many unexplained physical symptoms
Greater use of medical services
Walking Well

Spectrum of mood disturbance

Mild

thru to

Severe

Transience

thru to

Persistence

Continuous distribution in population

Clinically significant when:
(1) interferes with normal activities
(2) persists for min. 2 weeks
Diagnosis of depression / depressive disorder
Persistent & pervasive low mood
Loss of interest or pleasure in activities
Ennui

Epidemiology
2nd biggest cause of disability
worldwide by 2020 (WHO)
(IHD still the biggest)
Associated with increased
physical illness
5% during lifetime have MDD
1 in 20 consultations
100 patients per GP
MDD & Dysthmia > in females
20% develop chronic depression
30% of in-patients have depressive symptoms

Suicide

Suicide
Final clinical pathway
1 million deaths per year, 10-12 million attempts
UK

Males most common in older

Female most common in middle age

Steady decline since 1990

5,554 suicide deaths in UK 2006
15 per 100,000 deaths males
6 per 100,000 deaths females

Almost 50% fail on first attempt

Previous attempters 23 times more likely to dies from suicide than those
without previous attempts
Internal stress
Pre-existing psychiatric morbidity
Demographics
Opportunities

Stack 2001

Behavioural Indicators
- recent bereavement or other life-altering loss
- recent break-up of a close relationship
- major disappointment (failed exams or missed job promotion)
- change in circumstances (retire, redundant or children leaving home)
- physical illness
- mental illness
- substance misuse / addiction
- deliberate self-harm, (particularly in women)
- previous suicide attempts
- loss of close friend / relative by suicidal means
- loss of status
- feelings of hopelessness, powerlessness and worthlessness
- declining performance in work / activities (sometimes this can be reversed)
- declining interest in friends, sex, or previous activities
- neglect of personal welfare and hygiene
- alterations in sleeping habits (either direction) or eating habits

Case Summary of a Depressed Patient #1

Date

Symptoms

Referral

1985 (16) Anorexia

Secure unit teenagers

1986 (17) Suicide attempt

Secure unit teenagers

1986 (17) Self-harm

(A levels)

Secure unit CAMHS

Psychiatry - ECT unsubstantiated

1987-9
(18-20)

Self-harm. Anorexia
(university)

UMC

1990
(21)

Working as au pair
(left university)

GP monitoring & anti-depressants

1993
Self-harm
Secure unit admission
(24)
(joined commune)
Female. Abused by father from 6 to 15. Moved to boarding school, then to grandparents
Insomnia - Feeling worthless Guilt - Recurrent morbid thought - Bleak views - Self harm Suicide Ideation
Scholastically bright. University. Dropped out. Tried own business. Business failed.
Admin working.

Epidemiology
Depression more common in those with:

Life threatened / limited / chronic physical illness

Unpleasant / demanding treatment

Low social support

Adverse social circumstances

Personal / family history of depression / psychological vulnerability

Substance misuse

Anti-hypertensive / Corticosteroid / Chemotherapy use

L
o

Aetiology
Most depressions have triggering life events - Reactive depression
Especially in a first episode
Many patients present initially with physical symptoms (somatization)
Some may show multiple symptoms of depression in the apparent absence
of low mood - Masked Depression
Some depression has no triggering cause - Endogenous Depression
More persistent and resistant to treatment

Clinical Features

Adjustment Disorders
mild
short-lived
reactive episodes

Major Depressive Disorder (MDD)

5 symptoms displayed in 14 days

Dysthymia
depressed mood for 2+ years
not severe
chronic depression
unhealthy lifestyle associations

Bipolar Disorder / manic depression

major depression & mania

Major depression (DSM IV)

5 or more..
decreased interest / pleasure *
depressed mood *
reduced energy
weight gain / loss
insomnia / hypersomnia
feeling worthless
guilt
recurrent morbid thought
psychomotor changes
fatigue
poor concentration
pessimism / bleak views
self harm ideas / actions
suicide ideation

Classification of Depression (ICD-10)

Primary
Unipolar

Mixed anxiety and depressive disorder (prominent anxiety)

Depressive episode (single episode)
Recurrent depressive disorder (recurrent episodes)
Dysthymia - Persistent and mild ("depressive personality")

Bipolar

Bipolar affective disorder - manic episodes ("manic depression")

Cyclothymia - Persistent instability of mood
Other primary
Seasonal affective disorder
Brief recurrent depression
Depressive episode may be
Moderate or severe
With/Without somatic syndrome
With/Without psychotic symptoms

Somatization Syndrome (DSM IV)

4 or more..
Anhedonia
Loss of emotional reactivity
Early waking (>2 hours early)
Psychomotor retardation or agitation
Marked loss of appetite
Weight loss >5% of body mass in one month
Loss of libido

Linking Emotions with Physical Symptoms

Case Summary of a Depressed Patient #2

Date

Symptoms

Referral

1985 (17) Pervasive low mood

GP monitors

1986 (18) Suicide attempt

Child Psychiatry

1986 (18) Self-harm

Psychiatry

1987 (19) Anorexia. Self-harm

Psychiatry CPN

1988 (20) Suicide attempt

(failed romance)

Psychiatry CPN

1989 (21) Suicide attempt

(failed romance)

Psychiatry CPN

1990 (22) Fertility worries

Psychiatry CPN fertility counselling

1990 (22) Working in office

GP monitoring & anti-depressants

1992 (24) Self-harm

MH unit (open door policy) CPN

1996 (26) Chronic Fatigue

MH unit (open door policy) CPN

1998 (28) Fibromyalgia

MH unit (open door policy) CPN

Risk Factors Existing Health Conditions

Depressed Patients and Positive Symptoms

Rosemary Carson
Sensations of maggots moving within her body
Depressed, attempted suicide at the age of 15
Spent long periods of early adult life in psychiatric hospitals
Treated with medication and electro convulsive therapy
17-year remission in affective symptoms and sensations of maggots
By 1996 became ill again - began to hear voices
Her art captures memories of fellow patients and situations from earlier admissions

Depressed Patients and Positive Symptoms

Rosemary Carson - The Hospital Ward at Night

Classification
Many patients do not fit neatly into categories of either anxiety or depression
Mixed anxiety and depression is now recognised
Presence of physical symptoms indicates a somatic syndrome
Value of somatic features in predicting response to treatment is not clear
Presence of psychotic features has major implications for treatment
Brief episodes of more severe depression are also recognised
(brief recurrent depression)
More prolonged recurrence is now termed recurrent depressive disorder

Return to Work

10 20 30 40 50 60 70 80 90 100

% returning to work

Longer off work = Less likely to return to work

<1 2 4 6 8 10 12 14 16 18 20 22 24
months not working
Waddell, 1994

Risk Factors
Anxiety + Sadness + Somatic discomfort
Normal psychological response to life stress

Clinical depression is a final common pathway

Resulting from interaction of biological, psychological, and social factors
Likelihood of this outcome depends on many factors:
genetic and family predisposition
clinical course of concurrent medical illness
nature of any treatment
functional disability
individual coping style
social and other support

Risk Factors - Causality

Certain illnesses such (stroke, Parkinson's disease, multiple sclerosis, and
pancreatic cancer) may cause depression via direct bio mechanisms.
Stroke received most attention, but studies fail to show convincing direct
aetiology

Psychological Consequences of Chronic Illness

e.g. Cancer
Distress
Reduced QoL
Delay seeking help

Fear

Denial

Depressed / Anxious
Increased somatic complaints (Pain Fatigue Breathlessness)
Adjustment Disorder commonest psychiatric diagnosis
Neuropsychiatric complications
Increased risk of suicide in early stages

Depression in Cancer Patients

Response to perceived loss
Awareness of losses to come = bereavement
Loss of body, family, friends, role, life
Severe depression X4 likely in cancer patients
10-20% of cancer patients

Behavioural Responses to Diagnoses

Hedonism
Put life in order
Premature grieving

ADAPTIVE COPING
Talk about it
Planning
Changes

Sick Role
Illness Behaviour
Over-sensitivity to symptoms
Premature death

MALADAPTIVE COPING
Drink
Eat
Substance use

Neuropsychiatric Complications
Brain metastases:
Delirium
Dementia
Depression

Produce psych. symptoms before discovery

Paraneoplastic Syndromes
Neuropsychiatric problems in absence of metastases
Orig. lung, ovary, breast, stomach, or Hodgkins

Neuropsychiatric syndromes
61 yr old female
Frontal headaches for 3 months
Lethargic and weak
Difficulty walking
Diffuse areas of nodular destructive
lesions
Consistent with multiple myeloma or
metastatic disease
Skeleton is common site for mets from carcinomas and occasionally sarcomas
Lesions may be silent or symptomatic, such as pain, swelling, deformity,
compression of the spinal cord, nerve roots, or pathologic fractures.

Recognition & Diagnosis

Often missed in diagnoses
1. Distinguish depressed behaviour (sadness and loss of interest), from
realistic expected response to stress / physical illness
2. Confusion of whether physical symptoms of depression are due to
underlying medical condition
3. Negative attitudes to diagnosis of depression
4. Unsuitability of clinical setting for discussing personal & emotional
matters
5. Patients' unwilling to report symptoms of depression

Recognition & Diagnosis

Depressive illness is often under-diagnosed and under-treated
Especially if it coexists with physical illness
This often causes great distress for patients: mistakenly assumed
that symptoms (weakness or fatigue) are due to an underlying medical
condition.
Practitioners must be able to diagnose and manage depressive illness
Alertness to clues in interviews
Patients' manner
Use of screening questions can detect up to 95% of patients with major
depression.

Screening Questionnaires
How have you been feeling recently?
Have you been low in spirits?
Have you been able to enjoy the things you usually enjoy?
Have you had your usual level of energy, or have you been feeling tired?
How has your sleep been?
Have you been able to concentrate on your favourite tv shows?
Self-report screening instruments
Beck Depression Inventory (BDI)
General Health Questionnaire (GHQ)
Hospital Anxiety Depression Scale (HAD)
Cant replace systematic clinical assessment LISTENING
Persistent low mood and lack of interest and pleasure in life cannot be
accounted for by severe physical illness alone

Non-Specific Symptoms
Often missed in assessment

Prevalence of Non-Specific Symptoms

Symptom

Prevalence %

Stuffy nose
Headaches
Tiredness
Cough
Itchy eyes
Sore throat
Skin rash
Wheezing
Respiratory
Nausea
Diarrhoea
Vomiting
Heyworth & McCaul, 2001

46.2
33.0
29.8
25.9
24.7
22.4
12.0
10.1
10.0
9.0
5.7
4.0

Modern day complaints

Multiple Chemical Sensitivity
Chronic Fatigue Syndrome
Sick Building Syndrome
Gulf War Syndrome
Low-level Chemical Exposure
Electrical Sensitivity
Fibromyalgia
Historical complaints
Railway Spine
Neurasthenia
Combat Syndrome

Drug Treatment
Tricyclics
since the 1950s effective and cheap
limit compliance variable degrees of sedation
fatal in overdose (except Lofepramine)
dose-related anticholinergic side effects

postural hypotension

Monoamine Oxidise Inhibitors (MAOIs)

rare fatalities

tyramine-free diet

Selective Serotonin Re-uptake Inhibitors (SSRIs)

fluoxetine

lack sedation

no anticholinergic effects

improved compliance

less immediate benefit for disturbed sleep

safe in overdose

single or narrow range of doses works

Placebo & Nocebo

In approx. 30% of pop.
Subjected to more clinical trials than any other medicament
Nearly always does better than anticipated
The range of susceptible conditions seems limitless
Does not always occur
Present in subjective and objective outcomes
Negative outcomes can occur (Nocebo effect)
Placebo
Big pills better than smaller pills
Red pills better than blue
4 pills better than 2
30% of pop.

Long Term Prognosis

Identifying Unhelpful Patient Beliefs

Discuss potential unhelpful beliefs
Counter any simple aetiological beliefs
Outline biopsychosocial perspective
Can highlight potential perpetual factors that inhibit recovery
Agree on positive open minded approach
Do not argue over best name for condition!

Treatment
Much depressive illness of all types is successfully treated in primary care
Four main reasons for referral to specialist psychiatric services:
1) Condition is severe
2) Failing to respond to treatment (e.g. Psychomotor retardation)
3) Complicated by other factors (e.g. Personality disorder)
4) Presents particular risks (e.g. Agitation and psychotic behaviour)
Principal decision is whether to treat with drugs or a talking therapy
Most patients in primary care settings would prefer a talking therapy
Effectiveness is limited to particular forms of psychotherapy
Mild-Mod. Depression: CBT and antidepressants are equally effective
Severe Depression: antidepressant drugs are more effective

Management
The main aims of treatment:
improve mood and quality of life
reduce the risk of medical complications
improve compliance with and outcome of physical treatment
facilitate the "appropriate" use of healthcare resources
Primary care staff should be familiar with properties and use of:
1) common antidepressant drugs & brief psychological treatments
2) assessment of suicidal thinking and risk
Patients with more enduring or severe symptoms will usually require specific
treatment - usually drug therapy
For patients with suicidal ideation / whose depression has not responded to
initial management, specialist referral is the next step

Management
Low level risk

Clinical picture
Suicidal ideation
but no suicide attempts

Supportive environment
Physically healthy
No history of psychiatric illness

Action
Consider referral to mental health
professional for routine appointment
(not always necessary)

Management
Moderate level risk

Clinical picture
Low lethality suicide attempt
(patient's perception of lethality)

Frequent thoughts of suicide

Previous suicide attempts
Persistent depressive symptoms
Serious medical illness
Inadequate social support
History of psychiatric illness

Action
Refer to mental health professional
to be seen as soon as possible

Management
High level risk

Clinical picture
Definite plan for suicide
(When? Where? How?)

Action
Refer to mental health professional
for immediate assessment

Major depressive disorder

High lethality suicide attempt or multiple attempts
Advanced medical disease
Social isolation
History of psychiatric illness

Summary
Detection can be hard symptom overlap and patient unaware
Depression a natural occurrence in population
Whole range of depressive conditions with varying severity
Depression can be present in acute or chronic states
Depression can have physiological, biological or social causes
Depression may have a mixture of causes
Depression co-exists with many other symptoms
Depression is a natural reaction to disease diagnosis and presence
Depression and symptomotology are highly related