Hi, folks, I'm Bill Eaton. And this is major depression in the population, the public health framework. I'm going to present the first lecture on the burden of depression. And welcome to our course. So, this presentation is called What is Major Depression and Why is it Important? And I'm going to focus on the Burden of Depressive Disorder in the Population. I think in this course we keep mentioning the population. You'll see that we're going to take major depressive disorder and use it to exemplify and explain concepts of public health. So depression is the subject matter in a way, but the framework is going to be public health. So this is the outline of today's presentation. First thing is, what is depression like? Second thing, I'll tell you about the prevalence and incidence of depression. Those are two terms from epidemiology I'll define for you, and we'll show you how depression fits into those terms. Then I'll describe symptomatic course of depression and one of the aspects of the course of depression, which is very important and connected to the burden is, the fact that it precedes many important medical conditions, some of which are fatal. So that is new information we have over the last decade or so that raises the ante, really, for the importance of depressive disorder. And then I'll talk about something called Disability Adjusted Life Years, this is a way to quantify the burden of depression in the population, and the short is DALYs, d, a, l, y, s. And this comes out of a study called the Global Burden of Disease Study, and one of the things that happened in that study was people saw that depression, and depressive disorder, was much more important than they originally thought. So first section is what is depression? So here is the diagnostic criteria for depression from the so called Diagnostic and Statistical Manual of the American Psychiatric Association. What we have to start differentiating depression the mood from depression the clinical disorder. But we start with the moods. So one of these three abnormal moods has to be present for a diagnosis to be present. There has to be abnormal depressed mood, and it has to last for two weeks, nearly everyday, or, and one what might call abnormal depressed mood sometimes called dysphoria. But there's also this feeling of loss of interest or pleasure in things that you usually take pleasure in. They just don't give any pleasure and this is called anhedonia. And, again, this has to be present for two weeks, nearly everyday. For a young person, 18 or younger, irritable mood is one of the criteria but not for adults. And so now we have at least five of the following symptoms that have been present during the same two week depressed mood. So we have depressed mood. That's criterion A above. We have loss of interest and pleasure. That's criterion B that I talked about above. But then we have these other criteria and some of them are not so psychological, they're more having to do with the body. So loss of appetite, or gaining weight without trying to, or losing weight without trying to, or eating too much. That's an appetite disturbance. People with depressive disorder often have trouble sleeping. They wake up too early, or they can't get to sleep, or they sleep too late, there is a psychomotor disturbance, sort of a fussy agitation, but also a slowing. People with very, very severe depressive disorder, sometimes are nearly stuporous. They are just walking slowly, they're talking slowly, and it's very observable. But also, it just involves sometimes just a slowing that they notice. There is fatigue, or loss of energy. And then there's abnormal inappropriate guilt sometimes called WSG, which means worthless, sinful, guilty. And this is not just feeling bad about an accident that you've made with somebody or a temporary thing, it is people who will say over and over again, I'm sinful, I'm sinful, I'm sinful, I'm a shit, I'm a shit, I'm a shit, I should never have done that, and they just can't get it out of their mind. And there's poor concentration. People with depressive disorder often have troubles at work and one of the big reasons for that is that they can't think straight. And then, finally, we have thoughts of death or suicide, so called suicidal ideation and, or, suicidal behavior, that is, attempting suicide as part of the criteria for depressive disorder. So, this is a diagnosis, and this is what we call a syndrome, that means it's a group of signs and symptoms, and this group has to include depressed mood or anhedonia. But it also has to include at least four others. So we have five of the following symptoms have been present. And of those five, at least one must be either depressed mood or a loss of interest. So we have to be careful. Depression is a mood. It's an emotional feeling. It's sadness. I can make you depresses just by singing a sad song. Sad movies make me cry. You know, that sort of thing. But that's a temporary fleeting thing, doesn't involve the body, doesn't really affect the concentration too much. Major depression, the disorder, is what we're going to focus on in this course. And there are a few other criteria. They're not too important. The symptoms can be due to psychosis, can't be connected to mania, hence, you can get these symptoms from a physical illness, or from drinking too much, or from taking medications or street drugs. You can come down off methamphetamine and a two week low, and that's not major depressive disorder, that's something else. Now, the bottom line there is, the systems are not due to normal bereavement, and there is a big controversy about whether people who are bereaved and have all the systems of depressive disorder should be thought of as meeting the criteria for major depressive disorder. And just to give you a feeling for the way psychiatry works. Last year, the symptoms could not be due to normal bereavement, but we have the new diagnostic manual and this criteria has now been removed. And there's an argument about, if something happens regularly for bereavement, a man loses his wife suddenly, for example. He goes in to two week, or one month period, in which he has all the symptoms of depressive disorder, what should you do if you're a psychiatrist, for example? Should you treat him, or not? And the manual now says to use clinical judgement, which means leave it up to the psychiatrist to decide if the medication or treatment would help him. Depression's been around for a long time. This is just one etching from Durer called Melencolia from 1519, and you can see the guy on the right has a kind of a hostile, angry, or sad look. And a lot of this stuff is allegory, so we don't know what the sheep down there means, there is a number board up there that's probably cabal. And the idea is if you could straighten out those numbers and get them right, maybe he would recover. And the stone is the weight of depression. But this is just to illustrate. We can find examples of depressive disorder as far back as there is written literature. We can find them in the Mahabharata. If you remember the Bhagavad Gita opens with Arjuna's grief. For example, we can find Job being depressed. So there are descriptions of depressive disorder as far back as we have records of human writing. Now, just to, a little bit of an overview for depressive disorder. There are many, many different things that are thought to cause depressive disorder. But there are two big fat ones. One is inheritance, and we presume this is genetics that you inherit. And the other is stress. And this stress takes the form of loss, usually, so that a clinician treating somebody with depressive disorder almost all the time, not all the time, but nearly all the time, it will only take a few moments to discover that there has been a stress or a loss in that person's life in the immediate past. So let's look at the inheritance and depression. This is the family tree of Alfred Lord Tennyson. If you remember, Alfred Lord Tennyson was an English poet. He is one of the most gifted poets in the English language, in the romantic period, and a lot of the poetry he wrote beautifully about death. If you remember, he wrote Crossing the Bar, sunset evening star, one clear call from me. Let there be no moaning of the bar as I put out to sea. I mean, it's beautiful. Twilight evening bell. After that, the dark. Let there be no sad farewell when I embark. I mean, it's beautiful, but it's about death. It's a beautiful metaphor for death putting out to sea, well his family tree, you can see, when it's dark red or black its got depression, or rage, unstable moods. And at the bottom there you can see poor Al, at the bottom with, what is it one, two, three, four, five, six, seven, eight, nine, ten, eleven siblings of which five had depression and two had cholera. So Alfred Lord Tennyson was in a family of folks with depression. And this is an example, there wasn't anybody to diagnose him at the time, but this is an example of one of the poems that he liked the best that he wrote. It's called Maud, or The Madness, and if you just look for a little bit, you can see, I hate the dreadful hollow behind the little wood. Its lips in the field above are dabbled with blood red heath, he's getting there, sort of. The red ribbed ledges drip with a silent horror of blood, and echo there, whatever is asked her answers death. So you go up to this hollow and you say, hello down on the bottom, and it comes back, death. And then, there's a story, apparently his father took his own life. For there in the ghastly pit long since a body was found. His who had given me life. Father, God, was it well? Mangled, flattened, crushed, and dinted into the ground. So this is a sad poem, but he loved it. Apparently, Alfred Lord Tennyson liked to recite this poem, and people would come over for tea, and he would pull out the poem and try to recite it to them. So, it's just as much evidence as we have, that he was depressive, and it's an illustration of the inheritance of depression. This is an illustration of loss and depression. And the Buffalo Creek flood was, there's a small, one of these rivers in West Virginia, that's narrow and a little bit mountainous, and there was a coal mine at the top, and they'd take water out of the coal mine and put it behind a dam, dam maintained by the coal company. And there was a couple of days of rain and they didn't really pay too much attention to the quality of the structure of the dam, and it just broke. Poured down this river and they lost 125 people, with 1,100 injured and 4,000 people homeless. I'll show you some pictures right now. This is looking down, those are actually not blocks but houses that have been crushed by the flow of water. This is another view of the valley after the flood. And here's some folks trying to understand the fact that their home has been destroyed. And there is a memorial to the people who died in the Buffalo Creek flood. So this is an example of loss and stress in a disaster. This is an interview with a woman named Deborah, this is the word for word report of Deborah, who survived the flood. And I won't read the whole thing to you, but I have put in red, easy to understand the criteria of the major depressive disorder in the diagnostic manual, can't sleep, can't eat. She wanted to take a lot of pills and just go to bed and not wake up. So that's suicide, that's sleep problems, that's eating problems. Everything else in life that I had any interest in is destroyed, that's anhedonia. She cried all the time, that's sadness. I couldn't do nothing, that's kind of like fatigue. So it's as if she's residing back to the psychiatrist, the criteria of depressive disorder. And I'm showing you this because I want you to understand, no one would particularly think that Deborah had inherited depressive disorder. It was caused by the stress and the loss in Buffalo Creek Flood. And so we have these two separate, possible big set, of causes for depressive disorder, that's the point about this. That's the end of section A. We've covered what it is depressive disorder like, and how it's really different from sad mood. That it's a syndrome diagnosis with a collection of symptoms. And the idea is, it is sometimes is influenced by inheritance, and sometimes by loss. Now, we'll move on to section B, which we'll try to quantify the amount of depression in the population.
