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Major Depressive Disorder

Major Depressive disorder :-
   Life time risk of depression in males is 8-12% & in females is 20-26%
   Male : Female = 1:2
   Mean age of onset = 40 years (hence most common in middle age female)
   Core symptoms of depression -
  1. Depressed mood
  2. Easy fatigability
  3. Anhedonia (loss of interest in pleasurable activities)
Biological symptoms – Decreased appetite, weight loss (loss of >5% of body weight in Month)
Sleep especially – Early morning awakening
Psychomotor retardation –       
  1. Agitation           
  2. Reduced libido
Other symptoms –                       
  1. Inability to concentrate
  2. Ideas of hopelessness, worthlessness, low self esteem
  3. Death wishes, Suicidal ideation or attempt.
  4. Poor attention, forgetfulness,
  5. Crying spells
  6. Excessive guilt

Criteria for Major Depressive Episode (According to ICD 10)

Mild depression  - (2) +3 symptom of depression for 14 days.
Moderate - (2) +4 symptom for 14 days
- Without somatic syndrome
- With somatic syndrome

Severe  (2) +4 for 14 days
- Without psychotic features
- With psychotic symptoms
- Delusion of sin/guilt, Nilhistic Delusion (Cotard’s syndrome)
- Auditory hallucinations

Somatic Syndrome In Depression (Icd-10)

The somatic syndrome is characterized by:
  1. Significant decrease in appetite or weight loss → 5% in one month
  2. Early morning awakening, at least 2 (or more) hours before the usual time of awaking
  3. Diurnal variation, with depression being worst in the morning
  4. Pervasive loss of interest and loss of reactivity to pleasurable stimuli
  5. Psychomotor agitation or retardation.
Involutional melancholia
As the name suggests 'involutional melancholia', refers to the form of severe depression in which melancholia (Somatic symptoms) occur in involutional period of life (40-65 years). It is characterized by multiple somatic symptoms (Decrease in appetite/weight, early morning awakening, depression is worse in morning, psychomotor retardation or agitation, loss of interest in pleasurable activities, loss of reactivity to pleasurable stimuli excessive guilt). There may be Psychotic features (delusion of persecution, sin, guilt, poverty; Hallucination nihilistic ideas, and hypochondriacal delusions.
Agitated depression
This is a type of severe depression with marked motor restlessness or agitation. It is either seen alone or along with involutional melancholia. It is more common after the age of 40 years.
Psychotic features =
  1. Hallucinatory voices which are derogatory or calling to commit suicide abusive in nature.
  2. Delusion of sin/guilt, Nilhistic Delusion (Cotard‘s syndrome)
  3. Depressive Stupor
  1. Unipolar depression.                      
  2. Recurrent depression
  3. Bipolar depression – depression alternating with mania
  4. Depression due to general medical condition.
Other name of depression in 1960 were
  1. Reactive depression   -  Depression in reaction to some loss
  2. Endogenous depression -   Depression having Endocrinal basis/ not because of any stress.                               
Involutional Melancholia
  1. Described by Kraepelin, this is a form of severe depression which occurs in the Involutional period of life (i.e 40-45 years of age)
  2. Typically, Characterized by marked agitation, multiple somatic symptoms.
  3. Presently, it is no longer independent entity but to used to describe the severity of depressive episode.
Atypical Depression

Clinical feature
  1. Mood reactivity is present ie the mood brightens in response to actual or potential positive events.
  2. Weight gain or Increased appetite
  3. Hypersomnia
  4. Long standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance)
  5. Leaden paralysis- Patient would feel body is very heavy like Lead (heavy metal).
Treatment of Atypical depression= MAO Inhibitors (moclobemide, phenelzine).
Anaclitic depression
  1. Separation from the mother figure in 5 to 6 months during the infancy, leads to a infant crying relentlessly. Stops feeding and hence starts losing weight and does not goes in the lap of strangers (strangers anxiety)
  2. A picture simulating depression is named as a anaclitic depression (concept given by Rene spitz).


Biological theories

Genetic - Life time risk for the first degree relative of Bipolar mood disorder patient is 25% & of recurrent depressive disorder patients is 20%.
  1. If one parent Bipolar mood disorder risk is 27% & both parents it is 74%.
  2. Concordance rate in Bipolar disorder is 70% in Monozygotic twins & 20% for Dizygotic twins.
  3. Concordance rate in Unipolar depression is 50% in Monozygotic twins & 46% and for Dizygotic twins is 20%.
  4. Sleep studies

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