Snapshot A 27-year-old female presents with insomnia of recent onset stating that she has been waking up at 3 am every day. Upon further questioning the patient admits to feeling excessive fatigue lately and trouble focusing in school and at work. She also admits that she is no longer interested in high speed cup stacking (sport stacking) her previous life passion. The patient states that she has had a depressed mood lately and that she has thought about suicide at times. Major Depressive Episode Diagnostic criterion at least 5 of the following 9 symptoms for 2 weeks "SIG E CAPS" Sleep disturbance loss of Interest (anhedonia) Guilt or feelings of worthlessness loss of Energy loss of Concentration Appetite/weight changes Psychomotor retardation or agitation Suicidal ideations depressed mood must include depressed mood and anhedonia (inability to enjoy activities) can also present with subjective pain that is not related to anatomical structures Epidemiology lifetime prevalence 5-12% male 10-25% female increased risk with low socioeconomic status Biochemical changes ↓ NE, 5-HT, and dopamine Related disorders major depressive disorder, recurrent >/= 2 major depressive episodes 2 months symptom-free dysthymia milder form of depression lasting at least 2 years similar symptoms to major depressive disorder but patient can function seasonal affective disorder associated with winter season improves in response to full-spectrum light exposure atypical depression see below most common subtype of depression bipolar disorder according to the DSM-V manic symptoms can exist leading to a diagnosis with "mixed features" mixed features increases the likelihood that patient's condition exists on a bipolar spectrum major depressive disorder, with psychotic features symptoms of major depressive disorder in addition to simultaneous psychotic symptoms (most commonly auditory hallucinations), which do not occur outside of mood episodes Sleep Patterns of Depressed Patients Depressed patients show characteristic changes in sleep patterns ↓ slow-wave sleep ↓ REM latency ↑ REM early in sleep cycle ↑ total REM sleep repeated nighttime awakenings early-morning awakening improved symptoms with sleep deprivation Atypical Depression Characterized by hypersomnia overeating leaden paralysis (feeling of heaviness in limbs) mood reactivity i.e., can feel happy when happy events occur, not persistently sad Associated with weight gain sensitivity to rejection Treatment MAO inhibitors SSRIs combining these drugs increases the risk for serotonin syndrome Electroconvulsive Therapy (ECT) Treatment option for major depressive disorder refractory to other treatment and for pregnant women Produces a painless seizure in an anesthetized patient Major adverse effects disorientation anterograde/retrograde amnesia can be minimized when ECT is performed unilaterally Grief Normal grief - normally less than 6 months with a cause but normal grief can last up to 1 to 2 years shock denial guilt somatic symptoms may experience hallucinations of deceased person can precipitate a major depressive episode in a vulnerable individual (history of depression, family history) Pathologic grief - persistent and causes functional impairment excessively intense prolonged absent or inhibited grief delusions hallucinations Considered major depression when suicidal features appear greater than 6 months SIGE CAPS symptoms Postpartum Depression Postpartum "blues" considered "normal" 50-85% incidence depressed affect, tearfulness, fatigue follow up in 2 weeks if does not resolve mother unlikely to hurt baby Postpartum depression 10-15% incidence depressed affect, anxiety, poor concentration lasts 2 weeks to 2 months, then it is considered major depression treat with antidepressants and psychotherapy be watchful - mother may hurt infant though less likely Postpartum psychosis 0.1-0.2% incidence delusions, confusion, unusual behavior, and homicidal/suicidal ideation lasts days to 4-6 weeks treat with antipsychotics, antidepressants, and hospitalization if necessary ensure the baby is protected - highest likelihood mother will hurt baby