Major Depressive Disorder

1. Major Depressive Disorder

2. Mood Disorders • Extremely disabling, second only to heart disease • Associated with Suicide; 15% w/ MDD complete suicide • MDD most serous and widely studied depressive disorder • Individuals must have anhedonia or depressed mood for at least two weeks period of time

3. Epidemiology • Lifetime prevalence for any mood disorder is 20.8% • Lifetime prevalence for MDD is 16.6% (Kessler et al., 1994) • Dysthymia is less common (2.5%-6%)

4. Depression and etiology • 20 year old female college student presenting to the clinic. She was just released from an inpatient facility for attempting suicide. This has not been her first attempt. In addition to her frank suicide attempts she has engaged in a number of nonlethal self harm behaviors. She presents with major depression, severe and has nearly all of the melancholic features. Her speech is labored, her affect is blunted, her movements appear slow. Prior to her diagnosis of mdd she had a diagnosis of dysthymia.

5. Signs and Symptoms of MDD • Vegetative: loss of satisfaction, loss of interest in sex, early morning awakening, loss of appetite, loss of weight, social withdrawal • Cognitive Signs: Difficulty concentrating, indecisiveness, low self esteem, negative thoughts about the self, world and others, guilt, suicidal ideation and in more severe cases psychosis

6. Signs and Symptoms of MDD • Mood signs: feeling sad, empty, worried, hopeless and irritable

7. Dysthymia • Chronic low level depression lasting 2 years or more • Symptoms can not be absent more than 2 months at a time • Can not have MDD within the first 2 years of the disorder

8. Etiology • Twin Studies and Family studies Heritability and specific environmental factors such as stress affecting one twin but not the other appear to be important. --Correlation between MZ twins is .46, compared with DZ twins is .20. Genetic propensity exists but learning and environmental factors play an important role

9. Medical Illness • Endocrinological Disorders • Stroke • Parkinson’s Disease • Pancreatic Cancer • Coronary Heart Disease • Myocardial Infaction • Cerebrovascualr disease

10. Neuropsychology and Psychopharmacology • MRI studies revealed MDD have evidence structural differences compared with controls: • ventricular enlargements and sulcal space compared with control patients. Areas of impact include the frontal lobes, subcortical white matter and caudate nuclei

11. Neurotransmitters, Hormones and Depression • Monoamines • Norepinephrine • Serotonin • Dopamine • Cortisol

12. Personality • Prospective Studies and Temperament • Neuroticism

13. Stressors • Prolonged exposure to psychosocial stress • Most episodes are preceded by a severe life event or difficulty in the 6 months before the onset of the episode; • Increased rates of childhood abuse • Themes of loss • Maternal loss

14. Diathesis/Personality/Stress: Unipolar Depression • Diathesis • Females more at risk than males • Family history of unipolar depression • Monoamine Deficits • Diminished Norepinephrine • Diminished Serotonin • Diminished Dopamine • Personality • Neuroticism • Behavioral Inhibition • Anxiety • Social reticence • Fearful in presence of strangers • Lower sensation seeking Stressor Interpersonal Loss Threats to economic security Cummulative Negative Events Traumatic Events (defined by Criterion A)

15. Heterogeneity of Depression • Haslam and Beck • Examined empirical research for evidence of distinct subtypes of depression • Subtypes • Endogenous • Sociotropic • Autonomous • Self-critical • Hopelessness

16. Criteria for Analysis • Indicators must be dichotomous • Items were standardized • Was it a taxon? • Do the symptoms hang together? • Which elements appear important • Were they discrete or continuous?

17. Findings • Discrete subtype for endogenous depression

18. Heterogeneity of Depression: Male Presentations • http://www.nimh.nih.gov/health/publications/real-men-real-depression.shtml • http://www.nimh.nih.gov/health/topics/depression/men-and-depression/ /

19. The Masculine Depression Scale • Depression is twice as common in women as in men; • Perhaps men evidence depression symptomatology that is differerent from that of women and that these differences lead to disparate prevalence rates;

20. The Masculine Depression Scale • Developed a self-report instrument designed to assess ‘masculine depression’ • Examined the correlation between men who adhere to masculinity hegemonic norms and masculine depression

21. Sample items • Anger, aggression, irritability • Substance abuse • Withdrawal from family/social interactions • Overfocus on work/school • Inability or unwillingness to display soft emotions • Self-criticism of self/sense of failure

22. Findings • Men who adhered to masculine norms were more likely to endorse externalizing symptoms of depression than prototypic symptoms of depression • I’ve yelled at peoplor or things • I’ve had a short fuse • I got so angry I smashed or punched something • I don’t get sad I get mad • I’ve been drinking a lot • I’ve been under constant pressure • I’ve needed to handle my problems on my own