so let's talk about depression depression is in the soberest clinical terms a pretty big deal it's estimated that if you could snap your fingers and make depression disappear you would instantly eliminate 10 percent of all death and disability worldwide while doing that is unfortunately not possible what is doable is to recognize and treat depression using the best evidence-based practices when working with patients so that's what we're going to be focusing on in this video when talking about depression it's important to understand that what we currently call depression is most likely many different things for the sake of clarity we'll be focusing primarily on depression in its textbook form specifically episodic unipolar major depressive disorder and its various subtypes if you can learn these patterns down cold then not only will you be equipped to identify and treat the most common form of depression you'll also be primed to recognize cases that don't fit this pattern where another approach will likely be needed so with that in mind let's start by learning how to diagnose depression the key feature of depression is naturally depressed mood people in a state of depression generally feel terrible and will use words like sad empty hopeless gloomy miserable wretched and lonesome to describe their emotional state however beyond just feeling depressed there are additional features of depression that are often experienced as well these additional signs and symptoms of depression are captured in the now classic mnemonic ciggy caps legend has it that siggy caps refers to an outdated practice where a doctor writing a prescription would write sig for directions and then e-caps for energy capsules which is an older term for antidepressants you can use this memory device to remember that depression involves disturbances in the following area first is sleep with impaired sleep being experienced by more than 90 percent of people with depression depression causes not only difficulty falling asleep but also early morning awakenings disrupting both the amount and quality of sleep that people are able to get next is reduced interest or enjoyment from activities like participating in hobbies or socializing with others this hallmark symptom of depression is known formally as anhedonia anhedonia is what makes depression a non-reactive state meaning that someone's mood will remain the same no matter what's going on around them with someone in a state of depression feeling no joy even in situations that would normally inspire mirth such as celebrating a birthday or getting a promotion at work the g is for guilt or hopelessness people in a state of depression often find that their thoughts become focused on exclusively negative thoughts like guilt worthlessness or hopelessness these thought patterns are often ruminative with thoughts being chewed over repeatedly in the mind the e is for energy with levels of energy and activity being severely depleted in depression sometimes to the point where even getting out of bed in the morning is a major challenge the c is for concentration people in a state of depression often find it difficult to concentrate leading to impairments in work school and relationships the a is for appetite with the majority of people with depression finding that their appetite is decreased which can result in noticeable weight loss or even malnutrition over time people in a state of depression often describe food as unappetizing or flavorless almost like eating cardboard the p is for psychomotor retardation while most symptoms of depression can only be subjectively reported in some cases depression involves signs that can be objectively observed by others psychomotor retardation refers to a general slowing of speech and physical movements and is generally considered to be a sign of severe depression finally the s is for suicidal thoughts for people in the depths of depression suicide can sometimes seem like the only way out over half of all people who die by suicide were in a depressive episode at the time of their death making the link between depression and suicide quite clear having at least five of these nine symptoms for two or more weeks is diagnostic of a major depressive episode if you're going by dsm-5 criteria you can remember this by thinking that the time frame for depression is two blue weeks when diagnosing depression it's helpful to have some shortcuts to save you time while asking about all nine of these symptoms is the most thorough way of going about it you can effectively rule out a diagnosis of depression using just two symptoms depressed mood and anhedonia if the patient says that they aren't experiencing either of these things then you can feel confident that they aren't in an episode of depression even if you don't ask about the other seven symptoms so now that we've diagnosed depression let's look at some data about depression including who gets it what happens once they're diagnosed with it and any treatments to consider depression is the single most common psychiatric disorder with over 20 of all people experiencing at least one depressive episode in their lifetime this gives depression a high base rate in the population putting it high on your differential for all patients presenting with any kind of psychiatric concern depression can develop at any age although it begins most often in early adulthood with a median age of 32 however up to a quarter of people with depression don't have their first episode until after the age of 50 so a lack of prior episodes in an elderly patient does not automatically rule out major depressive disorder women are diagnosed with depression about twice as often as men across the lifespan the signs and symptoms of major depressive disorder tend to occur in discrete episodes untreated an episode of depression usually lasts between 6 and 12 months after this time most people will spontaneously recover and enter a period of normal mood known as euthymia functioning is often significantly impaired during an episode of depression but preserved between episodes after a single episode of depression the risk for developing another episode is about 50 it's a coin flip this means that as many as half of all people diagnosed with depression will only have a single isolated episode during their life for the other half however depression becomes a recurrent disorder with the risk of recurrence increasing to 80 after a second lifetime episode and getting even higher with each additional episode after that many people tend to think of depression as being caused by something but in reality the link between depression and life events is more nuanced than that the best way of conceptualizing it is to think that depressive episodes are sometimes but not always precipitated by life events generally these life events involve some form of disruption to one's social circumstances such as conflict with one's partner moving geographically being forced to change jobs or having a family member leave home the link between life events is clear as to our first lifetime episode of depression after that depression seems to take on a life of its own with episodes happening more and more often without a clear link to life events unfortunately depression carries a significant mortality rate mood disorders are found in the majority of people who die by suicide and up to five percent of people with depression will eventually take their own lives depression also worsens outcomes for a variety of medical illnesses including cancer heart disease and stroke leading to overall decreases in life expectancy of up to 10 years even after removing suicide from the equation with all that in mind let's think about what we can do to help treatment for depression consists of psychotherapy medications or a combination of the two while therapy and medications are both effective the combination is better than either one alone with treatment the average length of a depressive episode can be reduced from six months to less than three months in terms of therapy several types of psychotherapy appear to be helpful the most well studied is cognitive behavioral therapy or cbt which focuses on the connections between thoughts feelings and behaviors and teaches specific skills for breaking out of the cycle of depression medications used to treat depression are known as antidepressants most of these drugs work by increasing levels of various neurotransmitters like serotonin dopamine and norepinephrine that are active and available in the brain antidepressants are helpful for treating depression although it's important to point out that the medications can take some time to work with a full effect often not being seen for up to two months after starting the drug while treatment works for many people it is not 100 effective instead treatment response and depression appears to follow a rule of thirds with about one-third of patients receiving treatment experiencing complete recovery from their symptoms one-third noticing some improvement but not complete and one-third not getting any better with the first treatment tried patients who have not received any benefit even after multiple trials of therapy and medications are considered to have treatment-resistant depression in these cases other treatments such as electroconvulsive therapy or ect may be considered while ect is an invasive and complicated procedure it is highly effective with the largest effects seen of any single treatment for depression now that we have an understanding of diagnosis epidemiology prognosis and treatment for depression let's talk about a few subtypes of this disorder while each of these will introduce a few unique wrinkles into the equation they are all considered to be textbook depression as well so everything we've talked about so far will apply the first subtype is melancholic depression historically the melancholic specifier was used to describe severe episodes of depression that seemed to come out of the plu as opposed to being brought on by life events and were completely non-reactive to external circumstances so-called neuro-vegetative symptoms such as psychomotor retardation severe loss of appetite weight loss fatigue inattention and disturbed sleep are particularly pronounced melancholic depression is best thought of as a very severe form of the disorder and you may consider more intensive forms of treatment like ect earlier another subtype is atypical depression atypical depression has some unique features compared to textbook depression most notably mood remains reactive in atypical depression and many people will experience a lifting of depressive symptoms during happy life events or worsening of symptoms during sad life events patients with atypical depression often display a long-standing pattern of interpersonal rejection sensitivity even when not in an episode of depression other unique features are an increase in appetite rather than a decrease sleeping too much rather than too little and a sensation that one's limbs feel too heavy to lift a phenomenon known as lead in paralysis in terms of treatment a specific class of antidepressant known as monoamine oxidase inhibitors or maois is particularly effective for atypical depression you can remember the features of atypical depression by thinking of it as eight typical depression a depressed person who had mood reactivity and became happy when they ate food would probably start to gain weight causing their limbs to feel heavy and becoming sensitive to people ejecting them because of their weight postpartum depression develops in around 15 percent of women within a few weeks of delivering their child it's unclear why the postnatal state increases the risk of depression but many factors including hormonal changes sleep deprivation and child care stress are believed to play a role treatment is the same as for other cases of depression with the exception of taking some additional considerations into account when choosing medications if the mother is breastfeeding seasonal depression also known as seasonal affective disorder is a subtype of depression where episodes have a clear link to the changing of the seasons with depression generally developing during the winter months most likely due to lower levels of sunlight treatment of seasonal depression involves bright light therapy for at least 30 minutes a day although standard treatments for depression like meds and therapy are effective as well finally psychotic depression is characterized by the presence of paranoia delusions and or hallucinations in addition to all of the sigi-cap symptoms of depression that we talked about already treatment should involve a combination of both antidepressants and antipsychotics before we wrap up let's talk about related disorder known as dysthymia or more formally as persistent depressive disorder in the dsm-5 dysthymia is considered to be on the spectrum of depression but differs from major depressive disorder in two key ways first it is chronic rather than episodic with symptoms being present most of the time without a break for at least two years second it is sub-syndromal and that the patient does not quite meet full criteria for a major depressive episode but still suffers from depressed mood mood symptoms and dyslemia tend to avoid those symptoms of depression that are generally found often in more severe cases of depression such as psychomotor retardation or thoughts of suicide this suggests that dysthymia can be conceptualized as a milder but more chronic form of major depressive disorder and this idea is supported by the fact that treatment for dysthymia is largely the same as for textbook depression you can remember the common symptoms and time course of dysthymia using the mnemonic he's too sad to remind you of the hopelessness decreased energy low self-esteem abnormal sleep appetite changes and impaired decision making that are seen all for a minimum of two years up to a quarter of all patients with depression have both dysthymia and major depressive disorder a clinical situation known as double depression in these cases the patient spends large portions of their life in a chronic sub-syndromal state of dysthymia punctuated with discrete episodes of more severe depression double depression is notoriously difficult to treat but the approach to treatment remains the same therapy and or medications and that's it you should now have a solid foundation in our current understanding of major depressive disorder including how to both diagnose and treat it in clinical settings in the next video we'll talk about the other major mood disorder known as bipolar disorder if you're interested in learning more about depression check out my book memorable psychiatry which does a deeper dive into this material including an extensive comparison of depression with other diagnoses with which it is commonly confused as well as a bunch of practice questions to put your knowledge to the test good luck in your studies bye for now