3.4 Affective Disorders
Compact Summary
All Literature
, Depression: Lifetime Perspective
Hermann et al (2022) → Time for United Action on Depression: a
Lancet-World Psychiatric Association Commission
● Large review about how depression should be treated (risks, symptoms, care,
recommendations for the future)
● What is depression?
○ Controversies surrounding diagnostic criteria → continuous or categorical &
levels of severity (threshold issue)
○ Higher orders dimensions (underlying phenomena)
○ Specific types of depression → melancholic, psychotic, atypical, etc
○ Age → in older people underdiagnosed
○ Gender → more common in women
○ Culture → higher prevalence of somatic symptoms in non-western cultures
■ Higher association with suicidality in high income countries
○ Different from grief
● Epidemiology & burden
○ 4.7% has an episode in 12 months
○ 33-50% with depression have an episode in 12 month period
○ Persistent depression = 12% of all depression
○ Median age of onset = 26
○ Secondary peak of onset later in life
○ Subthreshold symptoms depression prevalence → 17%
■ Higher prevalence in children & adolescents
○ Comorbidities → anxiety, substance abuse & physical disorders (can be cause as
well as consequence of diseases)
○ Depression is most common disorder in suicide deaths
■ Most deaths occur during first episode
○ Impact on functioning → severe health condition, high disability (especially later
in life)
■ Effects on education, employment, economic, relationships, parent,
caregiving roles
● Causes & risk factors
○ Familial risk (often together with bipolar, substance abuse, anxiety)
○ Risk factors → genetic common variants, other psychopathology, early childhood
adversity, interpersonal styles & personality disorders, lifestyle, women, poverty
○ Protecting factors → secure attachment, cognitive abilities, self regulation,
community support
○ Precipitating factors → stressful life events, proximal environmental influences,
childhood sensitization (role in vulnerability)
, ○ Perpetuating factors → stress generation, substance abuse, behavior patterns,
cognitive biases, ruminative response style
○ Models of mechanisms
■ Probabilistic chain → conditioned by timing, dosage, context
■ Diathesis stress model → common theories (vulnerability to stressor)
■ Transactional model → vulnerabilities can change over time
■ Gene environment correlation → individual more likely to be exposed to
environment depending on gene (linked to diathesis stress)
■ Gut microbiome → complex interaction (linked to GABA & serotonin)
■ Environmental factors can be far removed from depression (time wise)
○ Neural pathways → many genetic variants (each low effect), frontal
hypometabolism & hippocampal atrophy, limbic & subcortical abnormalities
■ Not caused by just 1 gene → contemporary interconnected view
■ Mediators could be life stressors
● Public understanding
○ Negative attitudes → associated with negative outcomes
○ Higher stigma → men, unemployed, high cohesion affection communication
families
○ Less negative attitudes when attributed to spiritual problems, young people
○ Depression literacy → knowledge about strategies to maintain mental health
○ Acceptance is growing
○ Raising awareness → biomedical approaches unsuccessful, social contact
interventions greater benefit
● Interventions to reduce burden
○ Decrease stigma, improve literacy, advocacy, social contact
○ School based programs for younger people (bc of early onset)
○ Treatment preferences → psychotherapy > antidepressants (neg attitudes)
■ There is stigmatization in medical community
○ Prevention → prevention science & population health science
○ Universal, selective or indicated interventions
○ Proximal interventions → small effects
■ Costly & hard to implement but provides healthcare savings
■ Perinatal stage, childhood, adolescence, adulthood, older age
○ Distal determinants (affect proximal determinants) → poverty, inequality
○ Staged models (from prevention to treatment & care framework)
■ Early intervention is important → first episodes crucial, risk factors
○ Remission & recovery → CBT (mild), antidepressants (moderate/severe)
■ Combination works best
■ Non responders → electroconvulsive therapy
■ Spontaneous remission is possible
, ○ Self help & social interventions → moderate effect when guided
■ Support for lifestyle interventions, social not well studied
○ First line treatments → efficacy provent
■ Personal preference may moderate outcomes
■ Limitations → antidepressants have unwanted effects, withdrawal
○ Second & third line treatments → non response is common (50% do not achieve
remission in short term, treatment resistant depression)
■ Consider reasons for non response, safety of medications, subtype
■ ECT, TMS, GABA drugs (ketamine), mindfulness, ACT
○ Preventing relapse & recurrence → maintenance of pharmacotherapy
○ Problems with clinical practice vs RCT practice & results → wait list controls, high
heterogeneity, full treatment is completed in nonresponse, biases, comorbidities
○ Principles of care → same standards, only 10% receive effective care
■ Consider formulation, individual factors, good diagnostics
○ Collaborative care → team based health, social services, support services
■ Reaches underserved populations, family & person centered, low
resource availability, cost effective
Compact Summary
All Literature
, Depression: Lifetime Perspective
Hermann et al (2022) → Time for United Action on Depression: a
Lancet-World Psychiatric Association Commission
● Large review about how depression should be treated (risks, symptoms, care,
recommendations for the future)
● What is depression?
○ Controversies surrounding diagnostic criteria → continuous or categorical &
levels of severity (threshold issue)
○ Higher orders dimensions (underlying phenomena)
○ Specific types of depression → melancholic, psychotic, atypical, etc
○ Age → in older people underdiagnosed
○ Gender → more common in women
○ Culture → higher prevalence of somatic symptoms in non-western cultures
■ Higher association with suicidality in high income countries
○ Different from grief
● Epidemiology & burden
○ 4.7% has an episode in 12 months
○ 33-50% with depression have an episode in 12 month period
○ Persistent depression = 12% of all depression
○ Median age of onset = 26
○ Secondary peak of onset later in life
○ Subthreshold symptoms depression prevalence → 17%
■ Higher prevalence in children & adolescents
○ Comorbidities → anxiety, substance abuse & physical disorders (can be cause as
well as consequence of diseases)
○ Depression is most common disorder in suicide deaths
■ Most deaths occur during first episode
○ Impact on functioning → severe health condition, high disability (especially later
in life)
■ Effects on education, employment, economic, relationships, parent,
caregiving roles
● Causes & risk factors
○ Familial risk (often together with bipolar, substance abuse, anxiety)
○ Risk factors → genetic common variants, other psychopathology, early childhood
adversity, interpersonal styles & personality disorders, lifestyle, women, poverty
○ Protecting factors → secure attachment, cognitive abilities, self regulation,
community support
○ Precipitating factors → stressful life events, proximal environmental influences,
childhood sensitization (role in vulnerability)
, ○ Perpetuating factors → stress generation, substance abuse, behavior patterns,
cognitive biases, ruminative response style
○ Models of mechanisms
■ Probabilistic chain → conditioned by timing, dosage, context
■ Diathesis stress model → common theories (vulnerability to stressor)
■ Transactional model → vulnerabilities can change over time
■ Gene environment correlation → individual more likely to be exposed to
environment depending on gene (linked to diathesis stress)
■ Gut microbiome → complex interaction (linked to GABA & serotonin)
■ Environmental factors can be far removed from depression (time wise)
○ Neural pathways → many genetic variants (each low effect), frontal
hypometabolism & hippocampal atrophy, limbic & subcortical abnormalities
■ Not caused by just 1 gene → contemporary interconnected view
■ Mediators could be life stressors
● Public understanding
○ Negative attitudes → associated with negative outcomes
○ Higher stigma → men, unemployed, high cohesion affection communication
families
○ Less negative attitudes when attributed to spiritual problems, young people
○ Depression literacy → knowledge about strategies to maintain mental health
○ Acceptance is growing
○ Raising awareness → biomedical approaches unsuccessful, social contact
interventions greater benefit
● Interventions to reduce burden
○ Decrease stigma, improve literacy, advocacy, social contact
○ School based programs for younger people (bc of early onset)
○ Treatment preferences → psychotherapy > antidepressants (neg attitudes)
■ There is stigmatization in medical community
○ Prevention → prevention science & population health science
○ Universal, selective or indicated interventions
○ Proximal interventions → small effects
■ Costly & hard to implement but provides healthcare savings
■ Perinatal stage, childhood, adolescence, adulthood, older age
○ Distal determinants (affect proximal determinants) → poverty, inequality
○ Staged models (from prevention to treatment & care framework)
■ Early intervention is important → first episodes crucial, risk factors
○ Remission & recovery → CBT (mild), antidepressants (moderate/severe)
■ Combination works best
■ Non responders → electroconvulsive therapy
■ Spontaneous remission is possible
, ○ Self help & social interventions → moderate effect when guided
■ Support for lifestyle interventions, social not well studied
○ First line treatments → efficacy provent
■ Personal preference may moderate outcomes
■ Limitations → antidepressants have unwanted effects, withdrawal
○ Second & third line treatments → non response is common (50% do not achieve
remission in short term, treatment resistant depression)
■ Consider reasons for non response, safety of medications, subtype
■ ECT, TMS, GABA drugs (ketamine), mindfulness, ACT
○ Preventing relapse & recurrence → maintenance of pharmacotherapy
○ Problems with clinical practice vs RCT practice & results → wait list controls, high
heterogeneity, full treatment is completed in nonresponse, biases, comorbidities
○ Principles of care → same standards, only 10% receive effective care
■ Consider formulation, individual factors, good diagnostics
○ Collaborative care → team based health, social services, support services
■ Reaches underserved populations, family & person centered, low
resource availability, cost effective
