Major Depressive Disorder

What is major depressive disorder?

● Major depressive disorder is also known as Clinical depression ●
Common mental health disorder
● Estimated to affect 15% of the adult population
20% in Women ; 12% in Men
☆ Major depressive disorder impacts a person’s
● Mood
● Cognition
● Behavior
Subtypes of Major depressive disorder
There are several types of Major depressive disorder
● Seasonal affective disorder
● Psychotic depression
● Postpartum depression
● Melancholic depression
● Catatonic depression
● Atypical depression
● Persistent depressive disorder
• Seasonal affective disorder or SAD: It occurs mostly in the winter
months when sunlight is not properly available.
• Psychotic depression: Develops if person have been hallucinating or
if person have already had a form of depression in the past.
• Postpartum depression: It occurs between new mothers experiencing
hormonal changes during childbirth. In some cases it may occur prior
to birth as well. It is diagnosed as depressive disorder with peripartum
onset. Depression may occur during pregnancy or 4 weeks after birth.
• Catatonic depression: Person are most likely experiencing motor
problems and behavioral issues. It causes someone to remain
speechless and motionless for an extended period.
• Melancholic depression: Depression, including weight loss and
decreased interest in activities they once loved.
• Persistent depressive disorder- This is also known as Dysthymia.
Episodes of major depression accompanied with periods of less
serious symptoms. It last for 2 years or more with 2 or more following
symptoms: mild symptoms like change in appetite, change in sleep ,
fatigue/ low energy, decreased self esteem, decreased focus or
concentration, hopelessness or pessimism
• Atypical depression: characterized by improved mood when exposed
to pleasurable positive events. It is called mood reactivity. It can
develop symptoms like weight gain, increased appetite, over sleeping,
heavy limbs (aka) leaden paralysis, rejection sensitivity- feeling
anxiety about slight evidence of rejection.
SYMPTOMS OF MAJOR DEPRESSIVE
DISORDER
The Major Depressive Disorder (MDD) symptoms are the following:
• Low mood - depressed
• Anhedonia – decreased interest or pleasure
• Gaining or losing weight
• Sleep disturbance - inability to sleep or oversleep
• Psychomotor agitation or retardation
• Loss of energy or fatigue
• Feelings of low worth
• Decreased ability to think, concentration and make decisions
• Repeated thoughts of death, dying or suicide (a) suicidal thoughts with or w/o plan ;(b)
attempt of suicide
• Causes of major depression
is unknown
• It is due to combination of
several factors like Genetic,
Biological, environmental
and psychological
• Depression is a symptom
and not disease. Major
depressive disorder is also
called as chemical
imbalance.
CHANGE IN NEUROTRANSMITTERS
• Serotonin, Norepinephrine and Dopamine naturally present in brain
and assist communication between nerves cells.
• Low level of Serotonin can cause Depression by developing certain
symtoms like obsession and compulsion
• Serotonin plays an important role in maintain the mood balance.
• Low level of norepinephrine can cause anxiety and depression.
• Low level of norepinephrine is linked with ADHD . ADHD has mainly
3 types
• Low level of dopamine decreases attention, motivation and pleasure.
• Serotonin decrease may also be caused due to tryptophan depletion
• Tryptophan is an amino acid used to make serotonin in the body.
• Brain change: smaller frontal lobe and hippocampus volume.
• Other causes: Blunted circadian rhythm, specific changes in REM &
slow wave parts of sleep cycle, hormonal abnormalities like increased
cortisol, deregulation of thyroid hormone etc.
• Depression is caused due to Biological + Genetic and Biological +
Environmental causes:1. Death
2. Sexual abuse/ physical abuse
• There are many possible causes of depression, including faulty mood
regulation by the brain, genetic vulnerability, stressful life events,
medications, and medical problems.
Treatment
• Medications and psychotherapy are effective for most people with
depression.
• 70 – 80% may reduce symtoms with the right treatment.
• Two approches: pharmacological, non pharmacological
Non Pharmacological Approach
1. Physical exercise : help with increase in neurotransmitters,
endorphins, endocannabinoid. Increase body temperature and
decrease musle tension
2. Diet: healthy eating habits.
3. Psychotherapy for MDD
Psychotherapy or "talk therapy" -- is an effective treatment for MDD 
There are different type of MDD
Psychotherapy: Cognitive behavioral therapy:
Focus on how our own thoughts and behaviors contribute to
depression. The therapist will help us learn ways to react to things and
challenge our preconceptions.
Interpersonal therapy: Mainly Focuses on how our relationships with
others and also focus on practical issues. We have to learn how to spot
unhealthy behaviors and change them.
Psychodynamic therapy: It is traditional. The therapist explores
behavior patterns and motivations that we may not be aware of which
could contribute to depression.
Individual counseling: One-on-one session with MD
(psychiatrist/doctor), (psychologist) or one with experience in treating
depression and other mood disorders. The therapist will teach more
about depression and discuss new strategies to manage stress.
Family counseling: In this type the entire family is treated. If someone
is depressed, the entire family feels it, too. Several studies have shown
that family sessions might really help with treatment, too, improving
lifestyle, compliance with medication, and sleep habits.
• Pharmacological approach: incase of severe depression or mild depression
for longer period
• The treatment for major depressive disorder is a combination of
antidepressant medication such as:
1. Selective serotonin reuptake inhibitors (SSRIs) – inhibits reabsorption of
serotonin leaving adequate amounts in the synaptic cleft of neurons. .
Examples: Sertraline, Citalopram.
2. Serotonin-norepinephrine reuptake inhibitors (SNRIs). Examples:
Duloxetine, Venlafaxine.
3. Monoamine oxidase inhibitors ( MAOI) such as tranylcypromine,
phenelzine and isocarboxazid are used as a later option. • However
dangerous interactions may occur with foods such as certain cheeses,
pickles and wines and other herbal supplements.
4. Tricyclic antidepressants. Examples: Doxepin, Desipramine.
Final last line therapy for severe depression is ECT
• electroconvulsive therapy: under general anesthesia small controlled
Amount of current passed through brain
• May induce brief seizures
• It is used to impact the function and effect of neurotransmitters in the
brain.
Transcranial magnetic stimulation (TMS): uses magnetic pulses to
stimulate nerve cells in the brain that are involved in regulation of
mood.
• Incorrect Answers:
Answer 1: Add lithium may be appropriate as an adjunct agent in addition to
thyroxine both of which may improve the response to SSRIs (however this is not a
typical first- or second-line modification). It would be a potential option in treatment
after the patient failed her current SSRI including duration, dosing, and alternative
agents. Prior to diagnosing depression it is important to always check a TSH level
and treat any underlying hypothyroidism.
Answer 3: Increase dose of current medication could be appropriate if after a 6-8
week period, the patient's symptoms have not improved.
Answer 4: Switch to bupropion would be appropriate if this patient were trying to
quit smoking, or could not tolerate the sexual side effects of an SSRI. Bupropion
can lower the seizure threshold. Answer 5: Switch to paroxetine may be
appropriate if the patient does not respond to his current SSRI after 6-8 weeks of
therapy.

Bullet Summary:
SSRIs are the first line treatment for depression and should be continued for 4-8
weeks before changing therapy.