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<div class="noeditbox">Welcome to [[Pathophysiology of Complex Patient Problems|PT 635 Pathophysiology of Complex Patient Problems]] This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
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'''Original Editors '''- [http://www.physio-pedia.com/index.php5?title=User:Nadine_Risman Nadine Risman] from [[Pathophysiology of Complex Patient Problems|Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  
'''Original Editors ''' - [[User:Nadine Risman|Nadine Risman]] from [[Pathophysiology of Complex Patient Problems|Bellarmine University's Pathophysiology of Complex Patient Problems project.]]  


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== Definition/Description  ==
== Introduction ==


Depression is defined according to Goodman and Fuller as a morbid sadness, dejection, or a sense of melancholy distinguished from grief.&nbsp; Depression falls under the broader category of Major Depressive Disorders which are characterized by a single isolated episode lasting weeks to months.&nbsp; Major depressive disorders are viewed as an adjustment disorder which occurs due to external circumstances such as stress, trauma or loss.&nbsp; Other major depressive disorders include dysthymia and seasonal affective disorder.&nbsp; <br>
[[Image:Depression 2.jpg|right|150px]]Depression causes a persistent feeling of sadness and disinterest, clinical features being sadness, emptiness, and/or irritable mood. These features alongside body and mind changes can seriously affect  functional capabilities, and can lead to suicide<ref name=":0">WHO [https://www.who.int/news-room/fact-sheets/detail/depression Depression] Available: https://www.who.int/news-room/fact-sheets/detail/depression (accessed 12.9.2021)</ref>. Due to false perceptions, nearly 60% of people with depression do not seek medical help. The outcomes for patients with depression are cautious, with the condition having frequent relapses and remissions, leading to a poor [[Quality of Life|quality of life]].<ref name=":1">Chand SP, Arif H. Depression. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK430847/ (Accessed, 12/9/2021).
</ref>


== Prevalence  ==
This short video provides an overview of what depression actually is including discussion of symptoms, causes, and treatment.
{{#ev:youtube|v=fWFuQR_Wt4M|300}}<ref>Therapist Aid. What is Depression?. Available from: https://www.youtube.com/watch?v=fWFuQR_Wt4M [last accessed 22,1,2023]</ref>


Depression is the most commonly seen&nbsp;mood disorder within a therapy practice and is often associated with other physical illnesses and psychological conditions<ref name="Pathology">Goodman CC, Fuller KS. The Psychological Spiritual Impact on Health Care. In: 3rd ed: Pathology Implications for the Physical Therapist. St. Louis: Saunders Elsevier; 2009: 110-115.</ref>.&nbsp; In 2006, the Center for Disease Control conducted a study looking at the prevalence of depression.&nbsp; They found that&nbsp;approximately 15.7% of people reported being told by a health care provider that they had depression at some point in their lifetime.<sup>1&nbsp; </sup>Men and women ages 25 to 44 have the highest occurance of depression with the elderly population being the next highest age group affected.<ref name="CDC Website">Centers for Disease Control and Prevention. Anxiety and Depression. CDC Features. March 13, 2009. Available at: http://www.cdc.gov/Features /dsBRFSS Depression Anxiety/. Accessed on March 2, 2010.</ref>&nbsp;
== Etiology ==
The etiology of major depression involves many factors, with both genetic, social, lifestyle and environmental factors all playing a role.<ref name=":1" /><ref>Better health [https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/depression Depression] Available: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/depression (accessed 12.9.2021)</ref>
* First-degree relatives of depressed individuals are about 3 times as likely to develop depression as the general population; however, depression can occur in people without family histories of depression.
* [[Neurodegenerative Disease|Neurodegenerative]] diseases (especially [[Alzheimer's Disease|Alzheimer disease]] and [[Parkinson's|Parkinson disease]]), [[stroke]], [[Multiple Sclerosis (MS)|multiple sclerosis]], seizure disorders, [[Oncology|cancer]], macular degeneration, and [[Chronic Pain and the Brain|chronic pain]] have been associated with higher rates of depression.
* Life events and hassles operate as triggers for the development of depression.
* Environmental factors may make some people more vulnerable to depression, for example continuous exposure to violence, neglect, abuse or poverty.<ref name=":2">American Psychiatric  Association [https://www.psychiatry.org/patients-families/depression/what-is-depression Depression] Available: https://www.psychiatry.org/patients-families/depression/what-is-depression<nowiki/>(accessed 12.9.2021)</ref>
* Traumatic events eg death or loss of a loved one, lack of social support, caregiver burden, financial problems, interpersonal difficulties<ref name=":1" />.


[[Image:Map1 depression.gif|Image:Map1_depression.gif]]
== Epidemiology ==
Depression is a common illness worldwide, with more than 264 million people affected.<ref name=":0" /> Twelve-month prevalence of major depressive disorder is approximately 7%, with marked differences by age group. 


== Characteristics/Clinical Presentation  ==
* Prevalence in 18- to 29-year-old individuals is threefold higher than the prevalence in individuals aged 60 years or older.
* Females experience 1.5- to 3-fold higher rates than males beginning in early adolescence.<ref name=":1" />
* Close to 800 000 people die due to suicide every year. Suicide is the second leading cause of death in 15-29-year-olds<ref name=":0" />
[[File:Prevalence-of-depression-males-vs-females (1).png|center|frameless|740x740px]]


It is important to note that as many as one third of people experiencing depression do not feel sad or blue.&nbsp; Many experience somatic symptoms such as fatigue, joint pain, headaches, gastrointestinal disturbances,&nbsp;or chronic back pain.&nbsp; In Goodman and Synder, they report that 80 to 90% of the most common gastrointestinal disorders are associated with depressive or anxiety disorders.&nbsp; People with depression commonly have trouble sleeping, including early morning and frequent nocturnal awakenings.&nbsp; In the elderly population, sleep disturbances are the first symptom of depression especially when linked with acute confusion, falling, bowel and bladder problems or syncope.&nbsp; Clinical signs and symptoms can include:<ref name="Differential Diagnosis">Goodman CC, Snyder TK. Pain Types and Viscerogenic Pain Patterns. In: 4th ed: Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis: Saunders Elsevier; 2007: 153-157.</ref>
== Symptoms ==
Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease the persons ability to function at work and at home.


*Persistent sadness, low mood, or feelings of emptiness
Depression symptoms can vary from mild to severe and can include:
*Frequent or unexplained crying spells
*A sense of hopelessness
*Feelings of quilts or worthlessness
*Problems in sleeping
*Loss of interest or pleasure in ordinary activities or loss of libido
*Fatigue or decreased energy
*Appetite loss (or overeating)
*Difficulty in concentrating, remembering, and making decisions
*Irritability
*Persistant joint pain (arthralgia)
*Headache
*Chronic back pain
*Bilateral neurologic symptoms of unknown cause (e.g., numbness, dizziness, weakness)
*Thoughts of death or suicide
*Pacing and fidgeting
*Chest pain and palpitations


There may also be associated behavior changes that can include: compulsive, reckless or violent behavior, argumentative or oppositional behavior, patients may have a preoccupation with themselves, be critical toward family members (fault finding) or be unaffectionate with their partner or spouse.&nbsp; Other somatic symptoms that are associated with mood disorders in nonmedicated&nbsp;people&nbsp;includes:
* Feeling sad or having a depressed mood
* Loss of interest or pleasure in activities once enjoyed
* Changes in appetite — weight loss or gain unrelated to dieting
* Trouble [[Sleep Deprivation and Sleep Disorders|sleeping]] or sleeping too much
* Loss of energy or increased fatigue
* Increase in purposeless [[Physical Activity|physical activity]] (e.g., inability to sit still, pacing, handwringing) or slowed movements or speech (these actions must be severe enough to be observable by others)
* Feeling worthless or guilty
* Difficulty thinking, concentrating or making decisions
* Thoughts of death or suicide


*Muscle Pain (myalgia)
Symptoms must last at least two weeks and must represent a change in your previous level of functioning for a diagnosis of depression<ref name=":2" />.
*Excess Perspiration
*Dry Mouth or Excessive Salivation
*Rapid Breathing
*Blurred Vision
*Constipation
*Tinnitus
*Dry Skin
*Flushing
*Slurred Speech
*Amenorrhea, Polymenorrhea
*Digestive Problems


== Associated Co-morbidities <ref name="Differential Diagnosis" /> ==
=== Classification ===
[[File:Depression diagram.png|right|frameless|549x549px]]
Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies the depressive disorders into:


[[Image:Conditions Associated with Depression.GIF|Image:Conditions_Associated_with_Depression.GIF]]&nbsp;
* Disruptive mood dysregulation disorder
* Major depressive disorder
* Persistent depressive disorder (dysthymia)
* Premenstrual dysphoric disorder
* Depressive disorder due to another medical condition


Patients with these disorders are at higher risk for developing depression due to the disease pathology or medications associated with treating these disorders.
The common features of all the depressive disorders are sadness, emptiness, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function.<ref name=":1" />


== Medications  ==
== Treatment ==
[[File:Meditation.png|alt=|right|frameless|320x320px]]
Health-care providers should keep in mind the possible adverse effects associated with antidepressant medication, the ability to deliver either intervention (in terms of expertise, and/or treatment availability), and individual preferences. 


Depression may be caused by medications a patient is taking to treat another medical problem.&nbsp; Sedatives, hypnotics, cardiac drugs, antihypertensives, anticonvulsants,&nbsp;hormones&nbsp;and steriods are some drug catergories that can cause depression.&nbsp; Also recreational drugs such as alcohol and illegal drugs can cause signs and symptoms of depression.&nbsp; Some examples are as follows:<ref name="Pathology" />
Treatment can be widely classified into:  


'''Psychoactive Agents: '''Amphetamines, Cocaine, Benzodiazepines, Barbiturates, Neuroleptics
# Pharmacological treatment


'''Antihypertensive Drugs:''' Beta Blockers (especially propranolol), Alpha Adrenergic Antagonists, Methyldopa (Aldomet), Hydralazine (Apresoline)
* Antidepressant medication such as selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs).
* Antidepressants can be an effective form of treatment for moderate-severe depression but are not the first line of treatment for cases of mild depression.
* They should not be used for treating depression in children and are not the first line of treatment in adolescents, among whom they should be used with extra caution.<ref name=":0" />


'''Analgesics:''' Salicylates, Propoxyphene (Darvocet-N), Pentazocine (Talwin), Morphine, Meperidine (Demerol)
2. Non-pharmacological treatment/ pyschosocial therapy


'''Cardiovascular Drugs:''' Digoxin (Lanoxin), Procainamide (Pronestyl), Disopyramide (Norpace)
* are effective in mild depression without antidepressant.
* used side by side with antidepressant in case of moderate and severe depression.
* It includes:


'''Anticonvulsants:''' Phenytoin (Dilantin), Phenobarbital
a. Cognitive behavior therapy(CBT)


'''Hormonal Agents:''' Corticosteroids, Oral Contraceptives, Anabolic Steroids
b.  Problem solving therapy (PST)


'''Miscellaneous:''' Alcohol, Illicit Drugs, Histamine H<sub>2</sub> Receptor Antagonists (especially cimetidine or Tagamet), Metoclopramide (Reglan), Levodopa (Dopar, Larodopa), Nonsteroidal Antiinflammatory Drugs (NSAIDs), Antineoplastic Agents (Vinblastine), Disulfiram (Antabuse), Cytokines (Interferons)
c. Exercise


== Diagnostic Tests/Lab Tests/Lab Values  ==
d. Socialization


Depression is often under diagnosed by primary care physicians due to patients complaining of somatic pain rather than feelings of sadness.&nbsp; Physians tend to treat the somatic&nbsp;issues first through medication.&nbsp; Also the criteria in the DSM-IV makes diagnosing depression&nbsp;difficult because many patients don't fit the diagnostic criteria.&nbsp; Under the current DSM version the diagnosic criteria for a single episode of Major Depressive Disorder is:<ref name="Major Depressive Disorder">American Psychiatric Association. Major Depressive Disorder, Single Episode. DSM-5 Development. 2010. Available at: http://www.dsm5.org/ProposedRevisions/Pages/ proposedrevision.aspx?rid=44#. Accessed on March 5, 2010.</ref>
== Outcome Measures  ==
See [[:Category:Mental Health - Outcome Measures|Category:Mental Health - Outcome Measures]]


*A. Presence of a single Major Depressive Episode
== Physical Therapy Management  ==
*B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is&nbsp;not&nbsp;superimposed&nbsp;on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
*C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.


'''Note:''' This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.  
One of the biggest things a physical therapist can do for their patients is to be aware of the signs and symptoms of depression and some of the common disorders associated with depression. If the therapist is sensitive to the signs and symptoms of depression they can document it in the plan of care and then notify the physician so the patient can get the appropriate medical treatment, if necessary. Also, because patients with depression may be emotionally unstable, recognizing the signs and symptoms of depression can help you approach different situations and then redirect the patient toward other activities, instructions or more positive topics of conversation.


If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:  
Physiotherapy management of depression involves a holistic approach that combines physical activity and exercise with psychological support.<ref name=":3">Probst M. Physiotherapy and mental health. Clinical physical therapy. 2017 May 31;230:59-68.</ref> Physical activity has been shown to positively affect mood and mental well-being by increasing the release of endorphins, which are natural mood-boosting chemicals in the brain.<ref>Drannan JD. ''The relationship between physical exercise and job performance: the mediating effects of subjective health and good mood'' (Doctoral dissertation, Bangkok University).</ref> Physical activity can be an effective complementary treatment for individuals with depression.<ref name=":3" /> The American College of Sports Medicine recommends that adults engage in at least 150 minutes of moderate-intensity aerobic exercise per week, along with muscle-strengthening activities on two or more days. <ref>Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PD, Bauman A. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1081.</ref>Additionally, it is important to choose enjoyable and sustainable activities for long-term adherence, such as walking, cycling, swimming, or dancing.  Physiotherapists can also incorporate exercise and physical activity into their treatment plans as studies have shown that regular exercise can help alleviate symptoms of depression and improve overall mental health.<ref>Zhao JL, Jiang WT, Wang X, Cai ZD, Liu ZH, Liu GR. Exercise, brain plasticity, and depression. CNS neuroscience & therapeutics. 2020 Sep;26(9):885-95.</ref> Additionally, physiotherapists may use relaxation exercises, breathing exercises, and mindfulness-based interventions to help individuals manage stress and improve their mental health. These interventions can be tailored to the individual's specific needs.<ref name=":3" /> 


Mild, Moderate, Severe without Psychotic Features/Severe with Psychotic Features, Chronic,&nbsp;with Catatonic Features, with Melancholic Features, with Atypical Features, with Postpartum Onset
In addition, physiotherapist can also provide emotional support and encouragement to their patients with depression, which can help improve their overall mental health and well-being. By creating a positive and supportive environment, physical therapists can help their patients feel more comfortable and motivated to continue with their treatment plan. Thus, by promoting a healthy lifestyle, physical therapists can help their patients physically and mentally.


----
The video looks at evidence on how much exercise is required to get started in order to observe the beneficial effects of exercise in people with depression:


Dysthymic Disorder is a mild chronic depression that is characterized by more cognitive issues like low self esteem and hopelessness rather than problems with sleep or appetite.&nbsp; Many times those who have had a major depressive episode suffer from dysthymic disorder.&nbsp; Dysthymic is diagnosed on the following criteria listed in the DSM-IV. <ref name="Dysthymic Disorder">American Psychiatric Association. Dysthymic Disorder. DSM-5 Development. 2010. Available at: http://www.dsm5.org/ProposedRevisions/Pages/ proposed revision .aspx? rid=46#. Accessed on March 8, 2010.</ref>
{{#ev:youtube|v=QevFo8wsXZ4|300}}
See [[The Role of Exercise in Preventing and Treating Depression]]


*A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
Physical therapists can implement other strategies into their practice to further improve the effects of therapy beyond the benefits of exercise. Research has determined that a further decrease in depression symptoms can be obtained in the clinic by utilizing principles from the following:   
*B. Presence, while depressed, of two (or more) of the following:
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 1. Poor appetite or overeating
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 2. Insomnia or hypersomnia
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;3. Low energy or fatigue
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 4. Low self-esteem
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;5. Poor concentration or difficulty making decisions
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 6. Feelings of hopelessness
 
*C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
*D. No Major Depressive Episode has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
 
'''Note''': There may have been a previous Major Depressive Episode provided there was a full remission (no significant signs or symptoms for 2 months) before development of the Dysthymic Disorder. In addition, after the initial 2 years (1 year in children or adolescents) of Dysthymic Disorder, there may be superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be given when the criteria are met for a Major Depressive Episode.
 
*E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.
*F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
*G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
*H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
 
----
 
In the DSM-IV there is another category listed for the&nbsp;diagonosis of depressive disorders that do not&nbsp;meet the criteria of the other mood disorders. It is important to note that the psychosocial distress or dysfunction experienced must not be due to the physiological effects of&nbsp;a substance or a general medical condition.&nbsp; The Depressive Disorder Not Otherwise Specified category includes disorders with depressive features that do not meet the criteria for Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder With Depressed Mood, or Adjustment Disorder With Mixed Anxiety and Depressed Mood .&nbsp;
 
Sometimes depressive symptoms can present as part of an Anxiety Disorder Not Otherwise Specified. Examples of Depressive Disorder Not Otherwise Specified include:<ref name="Depressive Disorder Not Specified">American Psychiatric Association. Depressive Disorder Not Otherwise Specified. DSM-5 Development. 2010. Available at: http://www.dsm5.org/ProposedRevisions/Pages/ proposedrevision.aspx?rid=47#. Accessed on March 5, 2010.</ref>
 
*1. Premenstrual dysphoric disorder: in most menstrual cycles during the past year, symptoms (e.g., markedly depressed mood, marked anxiety, marked affective lability, decreased interest in activities) regularly occurred during the last week of the luteal phase (and remitted within a few days of the onset of menses). These symptoms must be severe enough to markedly interfere with work, school, or usual activities and be entirely absent for at least 1 week postmenses.
*2. Minor depressive disorder: episodes of at least 2 weeks of depressive symptoms but with fewer than the five items required for Major Depressive Disorder.
*3. Recurrent brief depressive disorder: depressive episodes lasting from 2 days up to 2 weeks, occurring at least once a month for 12 months (not associated with the menstrual cycle).
*4. Postpsychotic depressive disorder of Schizophrenia: a Major Depressive Episode that occurs during the residual phase of Schizophrenia.
*5. A Major Depressive Episode superimposed on Delusional Disorder, Psychotic Disorder Not Otherwise Specified, or the active phase of Schizophrenia.
*6. Situations in which the clinician has concluded that a depressive disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.
 
----
 
There are also several questionnaires that can be used to help determine if a patient is at risk for developing or has depression.&nbsp; The results of the questionnaire can help direct a patients referral to more qualified health care professionals.&nbsp; The following are a few examples of depression questionnaires.
 
'''The Beck Depression Inventory Second Edition''':&nbsp;21 item self-report form that is intended to assess the existance and severity of symptoms of depression in adilts and adolescents 13 year and older.&nbsp; The patient should answer the questions based on how they have felt for the last 2 weeks.&nbsp; There is&nbsp;a version of this test that can be used for medical patients that is a seven item self-report measure of depression in adolescents and adults that reflects the cognitive and affective symptoms of depression while excluding somatic and perfomrnace symptoms that might be attributable to other conditions.&nbsp; When scoring the Beck the higher the score the higher the feelings of depression are.&nbsp; All of the Beck Scales have been validated in assisting health care professionals in making focused and reliable client evaluations.
 
'''Geriatric Depression Scale (short form)''': 15 question self-report form that the patient answers based off how they have felt over the last week.&nbsp; Each question is worth one point and scores higher than 5 suggest depression and scores above 10 almost always indicate depression.
 
'''Zung Depression Scale:''' 20 question self-report form that the patient answers based off how often the statement describes how they have felt in the last several days.&nbsp; Each question is scored on a scale of 1 to 4 with higher scores indicating more feelings of depression.
 
== Causes  ==
 
There are several theories on why depression occurs based on biochemical mechanisms, neuroendocrine mechanisms, sleep abnormalities, genetics and psychosocial factors.<ref name="Pathology" />&nbsp;
 
'''Biochemical Mechanisms:''' an imbalance in the neurotransmitters norepinephrine and serotonin. Depression is caused when norepinephrine, dopamine and serotonin are produced in inadequate amounts or the receptor sites for these transmitters are not functioning properly. Excessive amounts of norepinephrine and dopamine results in a mania state commonly found in those with bipolar disorder.
 
'''Neuroendocrine Mechanisms:''' this results when there are abnormalities in the limbic hypothalamic-pituitart-adrenal (HPA) axis. There can be an over secretion of cortisol, suppressed nocturnal secretion of melatonin, and decreased prolactin production in response to tryptophan administration. There are also associations to some forms of depression when testosterone, follicle stimulating hormone and leuteinizing hormone levels are low. Knowing this information may result in a clinical lab test that can diagnose depression based off of low or high serum levels found in a blood test.
 
'''Sleep Abnormalities:''' sleep changes are consistantly associated with depression but there is some debate on whether sleep disturbances cause depression or if depression causes sleep disturbances. Those prone to depression will have decreased REM latency (the time between falling asleep and the first REM period), longer first REM period, less continuous sleep, and early morning awakenings.
 
'''Genetics: '''there does appear to be a genetic linkage of major depressive disorder in that it occurs up to three times more often in first degree biologic relatives of people with this disorder.
 
'''Psychosocial Factors:''' this includes things like major life events and percieved stress. While it is not clear if these things cause depression or are just a factor in determining those who are likely to develop depression. Often an episode of depression will follow a severe psychosocial stressor such as the death of a loved one. Also these types of stressors play a larger role in the first and second episodes of depression and a lesser role in a more chronic form of depression. <br><br>
 
== Systemic Involvement <ref name="Differential Diagnosis" /> ==
 
&nbsp;[[Image:Systemic Effects of Depression1.GIF|Data From: Smith NL: The effects of depression and anxiety on medical illness, University of Utah, School of Medicine, Stress Medicine Clinic, Sandy, Utah, 2002.]]
 
== Medical Management (current best evidence)  ==
 
The medical mangagement of depression revolves largely around the use of pharmacotherapy, psychosocial therapy and electroconvulsive therapy (ECT) also known as shock therapy.&nbsp;
 
== Physical Therapy Management (current best evidence)  ==
 
add text here
 
== Alternative/Holistic Management (current best evidence) ==
 
add text here


*[[Mindfulness]]<ref name="p2">Goodman CC, Fuller KS. The Psychological Spiritual Impact on Health Care. In: 3rd ed: Pathology Implications for the Physical Therapist. St. Louis: Saunders Elsevier; 2009: 110-115.</ref>
*[[Cognitive Behavioural Therapy]]&nbsp;<ref name="p3">Centers for Disease Control and Prevention. Anxiety and Depression. CDC Features. March 13, 2009. Available at: http://www.cdc.gov/Features /dsBRFSS Depression Anxiety/. Accessed on March 2, 2010.</ref><ref name="p4">Goodman CC, Snyder TK. Pain Types and Viscerogenic Pain Patterns. In: 4th ed: Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis: Saunders Elsevier; 2007: 153-157.</ref>
*Norwegian Psychomotor Physical Therapy&nbsp;<ref name="p5">Jacobsen LN, Lassen IS, Friis P, Videbech P, Licht RW. Bodily symptoms in moderate and severe depression. Nordic Journal of Psychiatry. 2006;60(4):294–8.</ref>
== Differential Diagnosis  ==
== Differential Diagnosis  ==


add text here
Differential Diagnosis include:  
 
== Case Reports  ==
 
add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
 
== Resources <br> ==
 
'''Geriatric Depression Scale (Short Form)'''


[http://www.stanford.edu/~yesavage/GDS.english.short.score.html http://www.stanford.edu/~yesavage/GDS.english.short.score.html]
* [[Anaemia]]
* [[Myalgic Encephalomyelitis or Chronic Fatigue Syndrome|Chronic Fatigue syndrome]]
* Dissociative disorders
* Illness anxiety disorders
* Hypoglycemia
* [[Schizophrenia]]
* Somatic symptom disorders<ref name=":1" />


'''Beck Depression Inventory II'''
[[Www.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm|www.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm]]
'''Zung Depression Scale'''
[http://healthnet.umassmed.edu/mhealth/ZungSelfRatedDepressionScale.pdf healthnet.umassmed.edu/mhealth/ZungSelfRatedDepressionScale.pdf]
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
<div class="researchbox">
<rss>Feed goes here!!|charset=UTF-8|short|max=10</rss>
</div>
== References  ==
== References  ==


see [[Adding References|adding references tutorial]].
<references />&nbsp;
 
[[Category:Bellarmine Student Project]]
<references />.
[[Category:Global Health]]
 
[[Category:Interventions]]
[[Category:Bellarmine_Student_Project]]
[[Category:Mental_Health]]
[[Category:Mental Health - Conditions]]
[[Category:Older People/Geriatrics]]
[[Category:Older People/Geriatrics - Conditions]]
[[Category:Non Communicable Diseases]]

Latest revision as of 13:23, 4 August 2023

Original Editors - Nadine Risman from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Lead Editors - Nadine Risman, Tessa Larimer, Admin, Lucinda hampton, Kim Jackson, Laura Ritchie, Tolulope Adeniji, Kirenga Bamurange Liliane, Simisola Ajeyalemi, Vidya Acharya, Manisha Shrestha, Elaine Lonnemann, WikiSysop, Amanda Ager, Lauren Lopez, 127.0.0.1, Wendy Walker and Evan Thomas

Introduction[edit | edit source]

Depression 2.jpg

Depression causes a persistent feeling of sadness and disinterest, clinical features being sadness, emptiness, and/or irritable mood. These features alongside body and mind changes can seriously affect functional capabilities, and can lead to suicide[1]. Due to false perceptions, nearly 60% of people with depression do not seek medical help. The outcomes for patients with depression are cautious, with the condition having frequent relapses and remissions, leading to a poor quality of life.[2]

This short video provides an overview of what depression actually is including discussion of symptoms, causes, and treatment.

[3]

Etiology[edit | edit source]

The etiology of major depression involves many factors, with both genetic, social, lifestyle and environmental factors all playing a role.[2][4]

  • First-degree relatives of depressed individuals are about 3 times as likely to develop depression as the general population; however, depression can occur in people without family histories of depression.
  • Neurodegenerative diseases (especially Alzheimer disease and Parkinson disease), stroke, multiple sclerosis, seizure disorders, cancer, macular degeneration, and chronic pain have been associated with higher rates of depression.
  • Life events and hassles operate as triggers for the development of depression.
  • Environmental factors may make some people more vulnerable to depression, for example continuous exposure to violence, neglect, abuse or poverty.[5]
  • Traumatic events eg death or loss of a loved one, lack of social support, caregiver burden, financial problems, interpersonal difficulties[2].

Epidemiology[edit | edit source]

Depression is a common illness worldwide, with more than 264 million people affected.[1] Twelve-month prevalence of major depressive disorder is approximately 7%, with marked differences by age group. 

  • Prevalence in 18- to 29-year-old individuals is threefold higher than the prevalence in individuals aged 60 years or older.
  • Females experience 1.5- to 3-fold higher rates than males beginning in early adolescence.[2]
  • Close to 800 000 people die due to suicide every year. Suicide is the second leading cause of death in 15-29-year-olds[1]
Prevalence-of-depression-males-vs-females (1).png

Symptoms[edit | edit source]

Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease the persons ability to function at work and at home.

Depression symptoms can vary from mild to severe and can include:

  • Feeling sad or having a depressed mood
  • Loss of interest or pleasure in activities once enjoyed
  • Changes in appetite — weight loss or gain unrelated to dieting
  • Trouble sleeping or sleeping too much
  • Loss of energy or increased fatigue
  • Increase in purposeless physical activity (e.g., inability to sit still, pacing, handwringing) or slowed movements or speech (these actions must be severe enough to be observable by others)
  • Feeling worthless or guilty
  • Difficulty thinking, concentrating or making decisions
  • Thoughts of death or suicide

Symptoms must last at least two weeks and must represent a change in your previous level of functioning for a diagnosis of depression[5].

Classification[edit | edit source]

Depression diagram.png

Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies the depressive disorders into:

  • Disruptive mood dysregulation disorder
  • Major depressive disorder
  • Persistent depressive disorder (dysthymia)
  • Premenstrual dysphoric disorder
  • Depressive disorder due to another medical condition

The common features of all the depressive disorders are sadness, emptiness, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function.[2]

Treatment[edit | edit source]

Health-care providers should keep in mind the possible adverse effects associated with antidepressant medication, the ability to deliver either intervention (in terms of expertise, and/or treatment availability), and individual preferences.

Treatment can be widely classified into:

  1. Pharmacological treatment
  • Antidepressant medication such as selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs).
  • Antidepressants can be an effective form of treatment for moderate-severe depression but are not the first line of treatment for cases of mild depression.
  • They should not be used for treating depression in children and are not the first line of treatment in adolescents, among whom they should be used with extra caution.[1]

2. Non-pharmacological treatment/ pyschosocial therapy

  • are effective in mild depression without antidepressant.
  • used side by side with antidepressant in case of moderate and severe depression.
  • It includes:

a. Cognitive behavior therapy(CBT)

b. Problem solving therapy (PST)

c. Exercise

d. Socialization

Outcome Measures[edit | edit source]

See Category:Mental Health - Outcome Measures

Physical Therapy Management[edit | edit source]

One of the biggest things a physical therapist can do for their patients is to be aware of the signs and symptoms of depression and some of the common disorders associated with depression. If the therapist is sensitive to the signs and symptoms of depression they can document it in the plan of care and then notify the physician so the patient can get the appropriate medical treatment, if necessary. Also, because patients with depression may be emotionally unstable, recognizing the signs and symptoms of depression can help you approach different situations and then redirect the patient toward other activities, instructions or more positive topics of conversation.

Physiotherapy management of depression involves a holistic approach that combines physical activity and exercise with psychological support.[6] Physical activity has been shown to positively affect mood and mental well-being by increasing the release of endorphins, which are natural mood-boosting chemicals in the brain.[7] Physical activity can be an effective complementary treatment for individuals with depression.[6] The American College of Sports Medicine recommends that adults engage in at least 150 minutes of moderate-intensity aerobic exercise per week, along with muscle-strengthening activities on two or more days. [8]Additionally, it is important to choose enjoyable and sustainable activities for long-term adherence, such as walking, cycling, swimming, or dancing.  Physiotherapists can also incorporate exercise and physical activity into their treatment plans as studies have shown that regular exercise can help alleviate symptoms of depression and improve overall mental health.[9] Additionally, physiotherapists may use relaxation exercises, breathing exercises, and mindfulness-based interventions to help individuals manage stress and improve their mental health. These interventions can be tailored to the individual's specific needs.[6]

In addition, physiotherapist can also provide emotional support and encouragement to their patients with depression, which can help improve their overall mental health and well-being. By creating a positive and supportive environment, physical therapists can help their patients feel more comfortable and motivated to continue with their treatment plan. Thus, by promoting a healthy lifestyle, physical therapists can help their patients physically and mentally.

The video looks at evidence on how much exercise is required to get started in order to observe the beneficial effects of exercise in people with depression:

See The Role of Exercise in Preventing and Treating Depression

Physical therapists can implement other strategies into their practice to further improve the effects of therapy beyond the benefits of exercise. Research has determined that a further decrease in depression symptoms can be obtained in the clinic by utilizing principles from the following:

Differential Diagnosis[edit | edit source]

Differential Diagnosis include:

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 WHO Depression Available: https://www.who.int/news-room/fact-sheets/detail/depression (accessed 12.9.2021)
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Chand SP, Arif H. Depression. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK430847/ (Accessed, 12/9/2021).
  3. ↑ Therapist Aid. What is Depression?. Available from: https://www.youtube.com/watch?v=fWFuQR_Wt4M [last accessed 22,1,2023]
  4. ↑ Better health Depression Available: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/depression (accessed 12.9.2021)
  5. ↑ 5.0 5.1 American Psychiatric Association Depression Available: https://www.psychiatry.org/patients-families/depression/what-is-depression(accessed 12.9.2021)
  6. ↑ 6.0 6.1 6.2 Probst M. Physiotherapy and mental health. Clinical physical therapy. 2017 May 31;230:59-68.
  7. ↑ Drannan JD. The relationship between physical exercise and job performance: the mediating effects of subjective health and good mood (Doctoral dissertation, Bangkok University).
  8. ↑ Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PD, Bauman A. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1081.
  9. ↑ Zhao JL, Jiang WT, Wang X, Cai ZD, Liu ZH, Liu GR. Exercise, brain plasticity, and depression. CNS neuroscience & therapeutics. 2020 Sep;26(9):885-95.
  10. ↑ Goodman CC, Fuller KS. The Psychological Spiritual Impact on Health Care. In: 3rd ed: Pathology Implications for the Physical Therapist. St. Louis: Saunders Elsevier; 2009: 110-115.
  11. ↑ Centers for Disease Control and Prevention. Anxiety and Depression. CDC Features. March 13, 2009. Available at: http://www.cdc.gov/Features /dsBRFSS Depression Anxiety/. Accessed on March 2, 2010.
  12. ↑ Goodman CC, Snyder TK. Pain Types and Viscerogenic Pain Patterns. In: 4th ed: Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis: Saunders Elsevier; 2007: 153-157.
  13. ↑ Jacobsen LN, Lassen IS, Friis P, Videbech P, Licht RW. Bodily symptoms in moderate and severe depression. Nordic Journal of Psychiatry. 2006;60(4):294–8.

 

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