3.4 Affective Disorders
Week 1
Depression Part 1
,What is Depression? → Overview
Herrman et al (2022)
Time for United Action on Depression: a Lancet-World Psychiatric
Association Commission
Executive summary
● Depression → leading cause of avoidable suffering
● Few communities & governments understand and acknowledge it as distinct from other
troubles
● This article aligns knowledge from many fields, synthesized evidence from many
contexts and generated actionable recommendations for many stakeholders
● Depression is common
○ Distinct from sadness, misery, despair
○ Profound suffering, impairs social functioning & economic productivity
○ Associated with premature mortality & physical illnesses
● Depression is heterogeneous
○ Experienced with various combinations of signs & symptoms, severity levels,
trajectories
○ The term in this case used broadly, does not relate to one diagnostic system or
category
● Core features have been described over thousands of years (universal)
○ Before the existence of classifications
○ It is not a modern condition or an invention of biomedicine or only experienced by
certain groups
● Each person experiences a unique combination of factors that lead to depression
○ Proximal adversities can trigger episode
○ Interact with genetic, environmental, social, developmental vulnerabilities &
resilience factors
○ Embrace the complexity of the disorder → go beyond brain-based or
social-environmental paradigm
● Individual level → detection and diagnosing of depression early is crucial to
recovery (staged approach)
○ Clinical formulation co-designed by the person with the experience, caregivers if
appropriate & clinicians is important to person-centered care
○ Accommodates heterogeneous presentation & unique personal stories, varies in
complexity & needs, resources
○ Adopting a staged approach to prevention and care is pragmatic for reaching
clinical decision about interventions that are evidence based
, ■ Low intensity early interventions aimed at interrupting and emerging
episode
■ Long-term multimodal care for people with recurrent/persistent depression
■ Range of intermediate interventions
○ Collaborative care models offer an evidence-based way for health systems to
implement staged approach to prevention & care (personalized at scale)
● Communities and professionals should support people with depression
○ Active role prevents stigma and helps meet needs of those unmet
○ Provides information about the condition & treatment possibilities
○ This will help those that experience people with recurrent depression and
advocate for greater resources
● Public health approach to depression is needed
○ Depression has social structural determinants and great severity, breadth and
durability and persistence for many people
○ Consequences include loss of lives and diminution of educational and work
opportunities and social connections, harm to future generations (impact of
parental depression
○ Preventative and health promoting actions at population & individual level is
crucial in lowering prevalence
○ Early detection and sustained care as needed
○ Collectively these interventions will promote overall health and achieve
sustainable development goals
● Healthcare practitioners should consider depression as a condition that affects
different people in different ways
○ Frequently accompanies other multifactorial illnesses & likely to complicate &
prolong the course of these conditions
○ Practitioners will be rewarded by efforts to integrate depression care in their
practice → better outcomes, priority to therapeutic alliance, addressing rights &
needs
● Public health & policy makers & researchers need to integrate depression
prevention into broader agendas
○ Mental health is central aspects of universal health coverage
○ New methods should be devised to optimize prevention, care, recovery
○ Approaches should be accessible in diverse resource contexts → profound
effects on those living in poverty & adversity
○ People with lived experiences of depression should be engaged in the design &
implementation of policies, services and research
Introduction
● Strides have been made in mental health awareness and prevention strategies
worldwide but still hampered by several issues (poor understanding, discrimination &
stigmatization)
● Depression is very heterogeneous & a global health crisis & found in all cultures
● It is not a biological disorder and simply a medical problem or social problem
, Section 1 → what is depression?
● Current diagnostic approaches
○ Conceptualized as a syndrome → associated
with stress & interference with personal functions
○ 5/10 symptoms have to be present for most of the
day, nearly every day for at least 2 weeks
○ Very similar ICD-11 & DSM-5 criteria
■ Hopelessness about the future is only
present in ICD
■ Diminished drive is a very predictive
symptom but in neither classification →
should be added in future
■ Other symptoms not in classification →
lack of mood reactivity, anger, irritability,
psychic anxiety, somatic components
● Continuous or categorical & question of severity
○ More controversial than the list of symptoms is
the amount of symptoms (at least 5)
■ Studies argued subthreshold depressions did not differ from diagnosable
depression in risk for future episodes, family history of mental illness,
comorbidities, functional impairment
■ Clinical utility of 5 symptom threshold has not been confirmed
○ Nuclear depressive syndrome → similar to melancholic depression
■ Most severe form
○ Depression is continuous rather than categorical
■ Threshold issue still not solved
■ Continuum of sadness to depression → reinforced medicalization of
sorrow
○ Subsyndromal depression should be its own syndrome (different from sadness)
○ Different levels of severity remain to be validly characterized → mild, moderate,
severe are rarely used in clinical practice
■ Usually scale of measurement instrument used → continuous
■ Symptoms may not have the same weight → bad way to measure
■ Complicated vs uncomplicated depression
● Psychopathological or oversimplification?
○ It is more than just severe sadness
○ Illness like symptoms, detachment from environment, feelings of inhibition
○ Somatic symptoms
● Higher order dimensions & specifiers
○ Often coexists with anxiety & bodily distress → could be different presentations of
the same underlying phenomenon (higher order category of disorder)
■ Subpopulations experience depression with different symptomatology
■ Different types of depression exist
Week 1
Depression Part 1
,What is Depression? → Overview
Herrman et al (2022)
Time for United Action on Depression: a Lancet-World Psychiatric
Association Commission
Executive summary
● Depression → leading cause of avoidable suffering
● Few communities & governments understand and acknowledge it as distinct from other
troubles
● This article aligns knowledge from many fields, synthesized evidence from many
contexts and generated actionable recommendations for many stakeholders
● Depression is common
○ Distinct from sadness, misery, despair
○ Profound suffering, impairs social functioning & economic productivity
○ Associated with premature mortality & physical illnesses
● Depression is heterogeneous
○ Experienced with various combinations of signs & symptoms, severity levels,
trajectories
○ The term in this case used broadly, does not relate to one diagnostic system or
category
● Core features have been described over thousands of years (universal)
○ Before the existence of classifications
○ It is not a modern condition or an invention of biomedicine or only experienced by
certain groups
● Each person experiences a unique combination of factors that lead to depression
○ Proximal adversities can trigger episode
○ Interact with genetic, environmental, social, developmental vulnerabilities &
resilience factors
○ Embrace the complexity of the disorder → go beyond brain-based or
social-environmental paradigm
● Individual level → detection and diagnosing of depression early is crucial to
recovery (staged approach)
○ Clinical formulation co-designed by the person with the experience, caregivers if
appropriate & clinicians is important to person-centered care
○ Accommodates heterogeneous presentation & unique personal stories, varies in
complexity & needs, resources
○ Adopting a staged approach to prevention and care is pragmatic for reaching
clinical decision about interventions that are evidence based
, ■ Low intensity early interventions aimed at interrupting and emerging
episode
■ Long-term multimodal care for people with recurrent/persistent depression
■ Range of intermediate interventions
○ Collaborative care models offer an evidence-based way for health systems to
implement staged approach to prevention & care (personalized at scale)
● Communities and professionals should support people with depression
○ Active role prevents stigma and helps meet needs of those unmet
○ Provides information about the condition & treatment possibilities
○ This will help those that experience people with recurrent depression and
advocate for greater resources
● Public health approach to depression is needed
○ Depression has social structural determinants and great severity, breadth and
durability and persistence for many people
○ Consequences include loss of lives and diminution of educational and work
opportunities and social connections, harm to future generations (impact of
parental depression
○ Preventative and health promoting actions at population & individual level is
crucial in lowering prevalence
○ Early detection and sustained care as needed
○ Collectively these interventions will promote overall health and achieve
sustainable development goals
● Healthcare practitioners should consider depression as a condition that affects
different people in different ways
○ Frequently accompanies other multifactorial illnesses & likely to complicate &
prolong the course of these conditions
○ Practitioners will be rewarded by efforts to integrate depression care in their
practice → better outcomes, priority to therapeutic alliance, addressing rights &
needs
● Public health & policy makers & researchers need to integrate depression
prevention into broader agendas
○ Mental health is central aspects of universal health coverage
○ New methods should be devised to optimize prevention, care, recovery
○ Approaches should be accessible in diverse resource contexts → profound
effects on those living in poverty & adversity
○ People with lived experiences of depression should be engaged in the design &
implementation of policies, services and research
Introduction
● Strides have been made in mental health awareness and prevention strategies
worldwide but still hampered by several issues (poor understanding, discrimination &
stigmatization)
● Depression is very heterogeneous & a global health crisis & found in all cultures
● It is not a biological disorder and simply a medical problem or social problem
, Section 1 → what is depression?
● Current diagnostic approaches
○ Conceptualized as a syndrome → associated
with stress & interference with personal functions
○ 5/10 symptoms have to be present for most of the
day, nearly every day for at least 2 weeks
○ Very similar ICD-11 & DSM-5 criteria
■ Hopelessness about the future is only
present in ICD
■ Diminished drive is a very predictive
symptom but in neither classification →
should be added in future
■ Other symptoms not in classification →
lack of mood reactivity, anger, irritability,
psychic anxiety, somatic components
● Continuous or categorical & question of severity
○ More controversial than the list of symptoms is
the amount of symptoms (at least 5)
■ Studies argued subthreshold depressions did not differ from diagnosable
depression in risk for future episodes, family history of mental illness,
comorbidities, functional impairment
■ Clinical utility of 5 symptom threshold has not been confirmed
○ Nuclear depressive syndrome → similar to melancholic depression
■ Most severe form
○ Depression is continuous rather than categorical
■ Threshold issue still not solved
■ Continuum of sadness to depression → reinforced medicalization of
sorrow
○ Subsyndromal depression should be its own syndrome (different from sadness)
○ Different levels of severity remain to be validly characterized → mild, moderate,
severe are rarely used in clinical practice
■ Usually scale of measurement instrument used → continuous
■ Symptoms may not have the same weight → bad way to measure
■ Complicated vs uncomplicated depression
● Psychopathological or oversimplification?
○ It is more than just severe sadness
○ Illness like symptoms, detachment from environment, feelings of inhibition
○ Somatic symptoms
● Higher order dimensions & specifiers
○ Often coexists with anxiety & bodily distress → could be different presentations of
the same underlying phenomenon (higher order category of disorder)
■ Subpopulations experience depression with different symptomatology
■ Different types of depression exist
