Major Depressive Major Depressive DisorderDisorder

Mood DisordersMood Disorders

Extremely disabling, second only to Extremely disabling, second only to heart diseaseheart disease

Associated with Suicide; 15% w/ MDD Associated with Suicide; 15% w/ MDD complete suicidecomplete suicide

MDD most serous and widely studied MDD most serous and widely studied depressive disorderdepressive disorder

Individuals must have anhedonia or Individuals must have anhedonia or depressed mood for at least two depressed mood for at least two weeks period of timeweeks period of time

EpidemiologyEpidemiology

Lifetime prevalence for any mood Lifetime prevalence for any mood disorder is 20.8%disorder is 20.8%

Lifetime prevalence for MDD is Lifetime prevalence for MDD is 16.6% (Kessler et al., 1994)16.6% (Kessler et al., 1994)

Dysthymia is less common (2.5%-Dysthymia is less common (2.5%-6%)6%)

Depression and etiologyDepression and etiology 20 year old female college student 20 year old female college student

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

Signs and Symptoms of Signs and Symptoms of MDDMDD

Vegetative: loss of satisfaction, loss Vegetative: loss of satisfaction, loss of interest in sex, early morning of interest in sex, early morning awakening, loss of appetite, loss of awakening, loss of appetite, loss of weight, social withdrawalweight, social withdrawal

Cognitive Signs: Difficulty Cognitive Signs: Difficulty concentrating, indecisiveness, low concentrating, indecisiveness, low self esteem, negative thoughts about self esteem, negative thoughts about the self, world and others, guilt, the self, world and others, guilt, suicidal ideation and in more severe suicidal ideation and in more severe cases psychosiscases psychosis

Signs and Symptoms of Signs and Symptoms of MDDMDD

Mood signs: feeling sad, empty, Mood signs: feeling sad, empty, worried, hopeless and irritableworried, hopeless and irritable

DysthymiaDysthymia

Chronic low level depression lasting 2 Chronic low level depression lasting 2 years or moreyears or more

Symptoms can not be absent more Symptoms can not be absent more than 2 months at a timethan 2 months at a time

Can not have MDD within the first 2 Can not have MDD within the first 2 years of the disorderyears of the disorder

EtiologyEtiology

Twin Studies and Family studiesTwin Studies and Family studiesHeritability and specific environmental Heritability and specific environmental factors such as stress affecting one factors such as stress affecting one twin but not the other appear to be twin but not the other appear to be important. important. --Correlation between MZ twins is .46, --Correlation between MZ twins is .46, compared with DZ twins is .20.compared with DZ twins is .20.

Genetic propensity exists but learning Genetic propensity exists but learning and environmental factors play an and environmental factors play an important roleimportant role

Medical IllnessMedical Illness

Endocrinological DisordersEndocrinological Disorders StrokeStroke Parkinson’s DiseaseParkinson’s Disease Pancreatic CancerPancreatic Cancer Coronary Heart DiseaseCoronary Heart Disease Myocardial InfactionMyocardial Infaction Cerebrovascualr diseaseCerebrovascualr disease

Neuropsychology and Neuropsychology and PsychopharmacologyPsychopharmacology

MRI studies revealed MDD have MRI studies revealed MDD have evidence structural differences evidence structural differences compared with controls:compared with controls:– ventricular enlargements and sulcal ventricular enlargements and sulcal

space compared with control patients. space compared with control patients. Areas of impact include the frontal Areas of impact include the frontal lobes, subcortical white matter and lobes, subcortical white matter and caudate nucleicaudate nuclei

Neurotransmitters, Hormones Neurotransmitters, Hormones and Depressionand Depression

MonoaminesMonoamines NorepinephrineNorepinephrine SerotoninSerotonin DopamineDopamine CortisolCortisol

PersonalityPersonality

Prospective Studies and Prospective Studies and TemperamentTemperament

NeuroticismNeuroticism

StressorsStressors

Prolonged exposure to psychosocial Prolonged exposure to psychosocial stressstress

Most episodes are preceded by a Most episodes are preceded by a severe life event or difficulty in the 6 severe life event or difficulty in the 6 months before the onset of the months before the onset of the episode;episode;

Increased rates of childhood abuseIncreased rates of childhood abuse Themes of lossThemes of loss Maternal loss Maternal loss

Diathesis/Personality/Stress: Diathesis/Personality/Stress: Unipolar DepressionUnipolar 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)

Heterogeneity of DepressionHeterogeneity of Depression

Haslam and BeckHaslam and Beck– Examined empirical research for Examined empirical research for

evidence of distinct subtypes of evidence of distinct subtypes of depressiondepression

– SubtypesSubtypes EndogenousEndogenous SociotropicSociotropic AutonomousAutonomous Self-criticalSelf-critical HopelessnessHopelessness

Criteria for AnalysisCriteria for Analysis

Indicators must be dichotomousIndicators must be dichotomous Items were standardizedItems were standardized Was it a taxon?Was it a taxon?

– Do the symptoms hang together?Do the symptoms hang together?– Which elements appear importantWhich elements appear important– Were they discrete or continuous?Were they discrete or continuous?

FindingsFindings

Discrete subtype for endogenous Discrete subtype for endogenous depressiondepression

Heterogeneity of Depression: Heterogeneity of Depression: Male PresentationsMale Presentations

http://www.nimh.nih.gov/health/publihttp://www.nimh.nih.gov/health/publications/real-men-real-depression.shtcations/real-men-real-depression.shtmlml

http://www.nimh.nih.gov/health/http://www.nimh.nih.gov/health/topics/depression/men-and-topics/depression/men-and-depression/depression/

/

The Masculine Depression The Masculine Depression ScaleScale

Depression is twice as common in Depression is twice as common in women as in men;women as in men;

Perhaps men evidence depression Perhaps men evidence depression symptomatology that is differerent symptomatology that is differerent from that of women and that these from that of women and that these differences lead to disparate differences lead to disparate prevalence rates;prevalence rates;

The Masculine Depression The Masculine Depression ScaleScale

Developed a self-report instrument Developed a self-report instrument designed to assess ‘masculine designed to assess ‘masculine depression’depression’

Examined the correlation between Examined the correlation between men who adhere to masculinity men who adhere to masculinity hegemonic norms and masculine hegemonic norms and masculine depressiondepression

Sample itemsSample items

Anger, aggression, irritabilityAnger, aggression, irritability Substance abuseSubstance abuse Withdrawal from family/social Withdrawal from family/social

interactionsinteractions Overfocus on work/schoolOverfocus on work/school Inability or unwillingness to display Inability or unwillingness to display

soft emotionssoft emotions Self-criticism of self/sense of failureSelf-criticism of self/sense of failure

FindingsFindings

Men who adhered to masculine norms Men who adhered to masculine norms were more likely to endorse externalizing were more likely to endorse externalizing symptoms of depression than prototypic symptoms of depression than prototypic symptoms of depressionsymptoms of depression– I’ve yelled at peoplor or thingsI’ve yelled at peoplor or things– I’ve had a short fuseI’ve had a short fuse– I got so angry I smashed or punched somethingI got so angry I smashed or punched something– I don’t get sad I get madI don’t get sad I get mad– I’ve been drinking a lotI’ve been drinking a lot– I’ve been under constant pressureI’ve been under constant pressure– I’ve needed to handle my problems on my ownI’ve needed to handle my problems on my own