Depression EXSS 3070 Lecture Notes

Mental Health Disorders and Depression

  • Mental disorders include abnormal thoughts, emotions, behavior, and relationships, treatable with disorders like schizophrenia and depression.
  • Mental illnesses cause changes in emotion, thinking, or behavior, leading to distress in social, work, or family life.
  • DSM-5 criteria define mental illness as a syndrome or pattern reflecting psychobiological dysfunction causing distress or disability, not merely a response to stressors or social deviance.
  • DSM-5-TR is the primary classification in the U.S. for mental disorders with diagnostic criteria.
  • ICD is not used in the US, but is used in 117 countries and comprises 17,000 diagnostic categories and 100,000 medical diagnostic index terms.
  • Drapetomania was a conjectural mental illness hypothesized in 1851 as the cause of enslaved Africans fleeing captivity; it was later widely mocked.

Mood and Affective Disorders

  • Mood is a conscious state of mind or emotion. Moods are less specific and intense than emotions and can have positive or negative valence.
  • Affective disorders involve elevation or lowering of mood that interferes with daily life.
  • Depression is classified with severity, from transient sadness to psychotic suicidal states.

Classification of Mood Disorders (Figure 1)

  • Mood Disorders:
    • Bipolar Disorders
      • Primary (Bipolar I, Bipolar II, Cyclothymic disorder)
      • Secondary (Substance/Medication-induced mood disorder)
    • Depressive Disorders
      • Disruptive Mood Dysregulation Disorder
      • Persistent Depressive Disorder
      • Major Depressive Disorder
      • Mood disorder due to a medical condition
      • Premenstrual Dysphoric Disorder
  • Epidemiological Statistics
    • 1 in 10 patients in primary care present with depressive symptoms.
    • Lifetime risk of depression is 15%, and 12-month prevalence is 4.1%.
    • Depression is twice as common in females than in males.
    • Mean age of diagnosis onset is 27 years, but 40% have first episode by the age of 20 years.
    • At least 80% of those affected by depression will experience at least two episodes of illness (recurrence) in their lifetime.
    • 54% of individuals recover within 6 months, 70% within one year.
    • 12-15% fail to recover and develop an unremitting chronic illness.
  • DSM-5-TR Criteria for Diagnosis of Depression Major Depressive Disorder & Minor Depressive Disorder
    • Major Depressive Disorder: At least five symptoms for most of the day during the same two-week period.
    • Minor Depressive Disorder: Two to four symptoms for most of the day during the same two-week period.
      Symptoms include:
    • Depressed mood
    • Diminished interest or pleasure
    • Significant weight change or appetite change
    • Insomnia or hypersomnia
    • Psychomotor agitation or retardation
    • Fatigue or loss of energy
    • Feelings of worthlessness or guilt
    • Diminished ability to think or concentrate, or indecisiveness
    • Recurrent thoughts of death or suicide
  • One of depressed mood or diminished interest must be present for diagnosis
  • In older adults, depression may present as loss of interest, emptiness, pessimism, rumination, anxiety, or cognitive impairment.
  • Cognitive impairments in late-life depression may persist even with treatment and increase the risk of dementia.
  • Treatment phases for Major Depressive Disorder include acute (6-12 weeks), continuation (4-9 months), and maintenance (≥1 year).
  • During a manic episode, people with bipolar I disorder experience an extreme increase in energy and mood changes, including feeling extremely happy or uncomfortably irritable.
  • DSM-5 describes primary criterion of mania as abnormally elevated, expansive, or irritable mood and increased goal-directed activity or energy.

Epidemiology of Depression

  • 12-month prevalence of major depressive disorder: 6%.
  • Lifetime risk of depression: 11-15%.
  • One in 10 primary care patients present with depressive symptoms.
  • Onset of first episode: adolescence to mid-40s.
  • 40% experience their first episode before age 20; average onset in mid-20s.
  • Gender ratio (F:M): 2:1.
  • Lifetime prevalence of bipolar disorder: 1%.
  • Lifetime prevalence of bipolar spectrum disorders: 2.5%.
  • Nearly half of patients experience recurrence within 2 years.
  • Mean age of onset in late teens, diagnosis in late 20s.
  • Ratio of manic to depressive episodes: 1:3.
  • Highest suicide risk (30-60 times general population).
  • Gender ratio (F:M): 1:.
  • Depression is a leading cause of disability and ill health worldwide.

Global and Australian Burden of Depression

  • Depressive disorders are the single largest contributor to non-fatal health loss (7.5% of all YLD).
  • Affects >1.3 million people in Australia (6% of population).
  • WHO estimates depression will be the number one health concern in developed and developing nations by 2030.
  • 1 in 5 Australians aged over 16 yrs experience a mental illness annually.
  • Most common illnesses: depressive, anxiety, and substance use disorders.
  • 45% of Australians will experience a mental illness in their lifetime.
  • Mood disorders are more prevalent in women.
  • Depression is the 4th most common problem managed by GPs.
  • Individuals with depression were 52% more likely to die from any cause over 4.5 years.

Suicide Statistics in Australia

  • Every day, >6 Australians die from suicide.
  • Men are at greatest risk but least likely to seek help; they account for 76% of suicide deaths (2011).
  • Suicide rate is 2x greater in Indigenous Australians.
  • Attempted suicide rate is 4x greater in the LGBTI community.
  • External factors causing depression:
    • Life stressors (family, interpersonal conflict, losses)
    • Drugs and alcohol.
  • Internal factors causing depression:
    • Medical illness or treatments
    • Past bad experiences
    • Personality and patterns of thinking
    • High anxiety
    • Chemical changes
    • Family disposition
  • Changes within the brain driven by stress underpin emotional disorders.
  • Psychosocial and environmental factors impact complex systems leading to clinical symptoms of mood disorders.
  • Stress hormones like cortisol link etiologies and co-morbidities of depression, including childhood adversity, socioeconomic disadvantage, lifestyle factors, and substance misuse.

Theories on the Pathophysiology of Depression Exist (Table 1)

  • Genetic vulnerability
  • Altered HPA (hypothalamic-pituitary-adrenal) axis activity
  • Deficiency of monoamines
  • Dysfunction of specific brain regions
  • Neurotoxic and neurotrophic processes
  • Reduced GABAergic activity
  • Dysregulation of glutamate system
  • Impaired circadian rhythms
  • Genetic and environmental influences include childhood abuse, neglect, losses, chronic diseases, and employment issues.
  • Potential bidirectional relationships exist among diet, sleep, and exercise and major depression.

Obesity and Depression

  • Bi-directional link between obesity and depressive illness in many cohort studies.
  • Obesity-Diabetes-Depression Link starts in utero

Link to Diabetes & Vascular Risk Factors

  • Depression and diabetes occur together ~2x as frequently as predicted.
  • Depression increases risk for diabetes by 37%; diabetes doubles risk of depression.
  • Depression and Comorbidity has high prevalence in HIV, T2D, CVD, Stroke, SUD, PTSD, aged care populations.
  • Depression treatment reduces symptoms and health care utilization.
  • Screen vulnerable cohorts for depression.
  • Quality of Life and Depression is Significantly impacted

Diagnosis and Management of Mental Health Disorders

  • Diagnoses/Referrals:
    • General Practitioners
    • Psychologists
    • Psychiatrists
    • Neurologists
    • Other medical professionals
  • Management/Prevention:
    • Medical practitioners/specialists
    • Allied health practitioners
    • Psychologists
    • Behavioral therapists
    • Counselors
    • Social workers
    • Art therapists
    • Exercise Physiologists
  • ANZJP Australian & New Zealand Journal of Psychiatry, 55(1) Clinical assessment and formulation of mood disorders.
  • Royal Australian and NZ College of Psychiatrists Care Pathway NOTE:
  • Completely different to APA Steps which start with Drugs and don’t include Lifestyle/Exercise
  • Royal Australian and NZ College of Psychiatrists Care Levels

Digital Interventions

  • Digital interventions for acute MDD should be provided in therapist-guided format
  • CBT delivered via the Internet (iCBT) is as effective as face-to-face psychological treatment for acute MDD
  • Australian Depression Programs
  • Management begins with Actions that need to be undertaken to facilitate functional recovery.

Pharmacotherapy and Other Treatments

  • Selective serotonin reuptake inhibitors (SSRIs)
  • Serotonin-noradrenaline reuptake inhibitors (SNRIs)
  • Selective noradrenergic reuptake inhibitors (NRIs)
  • Noradrenaline-dopamine reuptake inhibitor (NDRI)
  • Factors guide antidepressant choices: symptoms and side effects.
  • Exercise and Mental Health 2018 Physical Activity Guidelines Advisory Committee

Scientific Report: Exercise

  • Strong evidence demonstrates that moderate-to-vigorous physical activity reduces the risk of developing major depression.
  • It also reduces the symptoms of depression among individuals with and without clinical levels of depression.
  • Moderate-to-vigorous physical activity reduces general feelings of anxiety (trait anxiety) among individuals with and without anxiety disorders.
  • Acute episodes of moderate-to-vigorous physical activity also can reduce immediate feelings of anxiety (state anxiety).
  • Moderate-to-vigorous physical activity also can raise perceptions of one's quality of life and improves a variety of sleep outcomes among the general population as well as for individuals with symptoms of insomnia or sleep apnea.
  • Depressed mood and depression Reduced risk of depression Adults, ages 18 years and older Strong
  • Fewer depressive symptoms for individuals with and without major depression Strong
  • THE EFFECTS OF EXERCISE UPON THE RETARDATION IN CONDITIONS OF DEPRESSION
    Evidence comparing exercise to SSRI in managing depression • Blumenthal 1999
    All three interventions equally effective in both clinician rated, and self- reported depressive symptoms

Aerobic Dose

  • Low dose = 7 kcal/kg/week (3 or 5 days per week) NOT EFFECTIVE
  • Public Health Dose = 17.5 kcal/kg/week (3 or 5 days per week) = EFFECTIVE

PRT INTENSITY Study Design:

  • High Intensity PRT reduces depression significantly more than Low Intensity PRT or referral to GP for Usual Care Singh 2005

Exercise Intensity Scale

  • Effective PRT intensity for Depression: 80% 1RM or 15-18 Borg Scale, 3 d/wk
  • https://www.bmj.com/content/bmj/384/bmj-2023-075847.full.pdf: Strength training and yoga appeared to be the most acceptable modalities. Effective
  • Walking or jogging, yoga, and strength training more effective than other exercises, particularly when intense. Tolerated
  • Yoga and strength training were well tolerated compared with other treatments.

Mechanisms of Exercise Benefit

  • Mastery, self-efficacy
  • Internal locus of control
  • Self-esteem
  • Sense of purpose
  • Reduction in pain/frailty/mobility impairment
  • Dropout rates in trials of exercise for depression: PRT dropout lowest of all therapies assessed
  • Exercise is treatment for depression can be recommended as a stand-alone treatment and/or as an adjunct to antidepressant medication in resistant depression.

Recommendations

  • PRT or combined exercise has larger ES than aerobic exercise;
  • Efficacy (ES) is superior to CPT, IPT and antidepressants for treatment of major depression.
  • Exercise attenuates relapse rates:
  • Practical clinical studies are required to establish feasibility of longterm, unsupervised exercise.
  • Guidelines There are no ACSM guidelines/position stand for exercise prescription for depression
  • ESSA consensus statement related to exercise for mental health 84

What ESSA says AEPs can do

  • Provide basic healthy eating advice in the absence of a dietitian.
  • Provide in-service training for the mental health workforce on the implementation of exercise and physical activity in mental health settings.
  • Consult with mental health clinicians and GP’s on the most effective strategies to improve the health of clients including basic physical activity recommendations and referral pathways.
  • PHYSICAL HEALTH OUTCOMES Weight management Reduce the risk of chronic disease
  • Exercise prescription guidelines in depression. Important. Pre-exercise Assessment and Exercise Prescription Considerations
  • Practical Issues in Implementation of Exercise for MH Disorders: Stability of symptoms • Co-diagnoses • Other treatments • Setting/Supervision • Modality • Safety First: Do the benefits of exercise outweigh the risks?? SCREEN for Potential Cognitive Problems
  • https://www.racgp.org.au/getattachment/c1c9f4ab-1452-40d5-98dd-b6bf8111f566/attachment.aspx
    Important When physician referral is needed: MH or Cognitive dysfunction & Stability:
  • Common co-diagnoses include anxiety, depression, PTSD, insomnia, panic disorder
  • When to call the ambulance/ or refer?
  • TeleHealth for exercise delivery in MH ?
  • https://www.essa.org.au/wp-content/uploads/2018/08/Exercise-
    Mental-Health-
    eBook_v6.pdf?ss360Query=essa%20%20mental%20health
  • Comorbidity is the norm
  • Use it like the drug it is….But not only. Collaborate