Depression is characterised by a depressed mood or a loss of interest or pleasure in activities. Symptoms of depression include changes in appetite, weight, sleep, or psychomotor activity. There is often decreased energy, feelings of worthlessness or guilt, difficulty concentrating or making decisions, and thoughts of death or suicide. Depression may also be associated with increased hopelessness, which is the absence of positive future orientation. This topic concentrates on depressive disorders in PTSD. Please also see the topic on depressive symptoms under signs and symptoms of PTSD.

What is the evidence for depressive disorders?

Moderate to high quality evidence finds around 52% of people with PTSD also have a major depressive disorder. Military samples had higher rates than civilian samples, and people exposed to interpersonal traumas had higher rates than people exposed to natural disasters.

Moderate to low quality evidence finds a medium-sized increase in rates of depressive disorders in prisoners with PTSD compared to those without PTSD. Rates were highest in males, in adult prisoners, and in prisoners with any lifetime diagnosis of PTSD.

August 2021

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Bipolar disorders are a group of disorders characterised by episodes of mania or hypomania and depression. In between episodes, mild symptoms of mania and/or depression may, or may not, be present. The bipolar disorders include bipolar I, bipolar II, and cyclothymic disorder. Bipolar I disorder is characterised by mania, while bipolar II disorder is characterised by less severe hypomania. Cyclothymic disorder is the mildest of the bipolar disorders.

A major depressive episode is at least two weeks of at least five of the following symptoms. Intense sadness or despair; feelings of helplessness, hopelessness or worthlessness; loss of interest in activities once enjoyed; feelings of guilt, restlessness or agitation; sleeping too little or too much; slowed speech or movements; changes in appetite; loss of energy; difficulty concentrating, remembering or making decisions; and/or thoughts of death or suicide.

A manic episode is at least one week of extremely high spirits or irritableness most of the time. A manic episode involves changes in normal behaviour. These include exaggerated self-esteem, less sleep, talking a lot and loudly, being easily distracted, doing many activities at once, risky behaviour, uncontrollable racing thoughts, and quickly changing ideas or topics. These changes in behaviour are significant and clear to friends and family and are severe enough to cause major dysfunction. A hypomanic episode is similar to a manic episode but less severe and need only last four days. Hypomanic symptoms do not lead to major dysfunction that mania often causes.

What is the evidence for rates of bipolar disorders in people with PTSD?

Moderate quality evidence finds current bipolar disorder in people with PTSD ranges between 4% for bipolar II disorder and 19% for bipolar I disorder. For any lifetime diagnosis, the rate ranges between 20% for bipolar II disorder and 35% for bipolar I disorder.

August 2021

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For a diagnosis of PTSD, there needs to be at least two “negative alterations in cognitions and mood”. These include negative thoughts or feelings that began or worsened after the trauma, an inability to recall key features of the trauma, overly negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others for causing the trauma, negative affect (e.g., fear, horror, anger, guilt, or shame), decreased interest in activities, feeling isolated, and difficulty experiencing positive affect.

What is the evidence for negative thoughts and mood in PTSD?

Moderate to high quality evidence found a strong relationship between increased dysfunctional appraisals of the trauma and increased PTSD symptoms in children and adolescents. Increased shame was related to increased PTSD symptoms in adults. There was also a relationship between increased symptoms and increased guilt, particularly feelings of wrongdoing and self-blame. In veterans, poor mental health in general, poor social functioning, more substance use and more aggression were related to more emotional numbing. However, more treatment initiation and better treatment retention were also related to more emotional numbing in veterans.

Moderate to low quality evidence found decreased reward functioning in people with PTSD, being a reflection of an inability to feel pleasure. There was less anticipation and approach reward functioning, and also decreased hedonic responses.

Moderate to low quality evidence finds five clusters of items relating to negative alterations in cognition and mood. These are;

Decreased interest items

I lost interest in activities which used to mean a lot to me. I lost interest in my usual activities. I lost interest in free time activities that used to be important to me. I lost interest in social activities. I lost interest in activities that I used to enjoy.

Detachment items

I felt distant or cut off from people. No one, not even my family, understood how I felt.

Restricted affect items

I was not able to feel normal emotions. It seemed as if I have no feelings. I felt emotionally numb. I felt unemotional about everything. I was unable to have loving feelings for people who are close to me.

Foreshortened future items

I felt as if my plans for the future would not come true. I felt that I had no future. Making long term plans seemed meaningless to me. I felt as if I don’t have a future. I felt as if my future would somehow be cut short.

Guilt items

I felt guilty. I felt ashamed of the traumatic events that happened to me. I blamed myself. I felt guilt over things I did around the time of the event. I felt guilty for having survived.

August 2021

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Depression symptoms are common in people with PTSD. It is characterised by a depressed mood and a loss of interest or pleasure in activities. Symptoms of depression can also include changes in appetite, weight, sleep, or psychomotor activity, decreased energy, feelings of worthlessness or guilt, difficulty concentrating or making decisions, and thoughts of death or suicide. Depression may also be associated with increased hopelessness, which is the absence of positive future orientation.

This topic concentrates on the occurrence of depressive symptoms rather than depressive disorders in PTSD. Please see the co-occurring mental disorders topic for information on comorbid depressive disorders in people with PTSD.

What is the evidence for depression symptoms in people with PTSD?

Moderate to high quality evidence finds a medium-sized correlation between increased PTSD symptoms and increased depressive symptoms. This was found in North Korean refugees and in cancer patients. In North Korean refugees, the relationship was stronger in adults than in youths, and stronger in refugees with more than five years outside of North Korea, although the effect sizes were all medium-sized.

August 2021

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Depression is characterised by a depressed mood and/or a loss of interest or pleasure in activities. Symptoms of depression include changes in appetite, weight, sleep, and psychomotor activity, decreased energy, blunted affect, social withdrawal, difficulty concentrating or making decisions, feelings of worthlessness, hopelessness and guilt, and thoughts of suicide. As many symptoms are common to both depression and the negative syndrome of schizophrenia it can be difficult to identify a comorbid depressive illness in people with schizophrenia. Identifying and treating a comorbid depressive illness may increase the likelihood of recovery from psychosis and reduce the likelihood of psychotic relapse.

What is the evidence for medications for depression in people with schizophrenia?

For adjunctive antidepressants compared to placebo or no adjunctive treatment, moderate quality evidence finds a small effect of greater improvement in depressive symptoms with adjunctive antidepressants.

For antipsychotics alone compared to placebo, moderate to high quality evidence finds a large effect of greater improvement in depressive symptoms with sulpiride. There were medium-sized improvements with clozapine, amisulpride, and aripiprazole over placebo. There were small improvements with olanzapine, cariprazine, paliperidone, asenapine, quetiapine, risperidone, ziprasidone, lurasidone, haloperidol, and brexpiprazole. There were no improvements over placebo with clopenthixol, sertindole, flupentixol, chlorpromazine, perphenazine, zotepine, zuclopenthixol, thiotixene, loxapine, penfluridol, pimozide, perazine, trifluoperazine, molindone, or levomepromazine.

Moderate to low quality evidence suggests the antipsychotic clozapine may improve depression symptoms more than any other antipsychotic combined with the antidepressants amitryptiline, mianserin, meclobemide or placebo.

October 2020

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Bipolar disorders are a group of disorders characterised by episodes of depression and mania or hypomania. Bipolar disorders described in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, version 5) include bipolar I disorder involving severe depression and mania, bipolar II disorder involving depression and hypomania (less severe mania), and cyclothymic disorder involving many mood swings, with hypomania and depressive symptoms occurring often and fairly constantly.

Major depressive disorder characterised in the DSM-5 involves five (or more) of the following symptoms to be present and represent a change from previous functioning. At least one of the symptoms must be either depressed mood or loss of interest or pleasure, with no history of mania.
• Depressed mood most of the day, nearly every day
• Diminished interest/pleasure in all, or almost all, activities most of the day, nearly every day
• A change of more than 5% of body weight in a month or decrease/increase in appetite
• Insomnia or hypersomnia
• Fatigue or loss of energy
• Psychomotor agitation or retardation that is observable by others
• Feelings of worthlessness or excessive or inappropriate guilt
• Diminished ability to think or concentrate, or indecisiveness
• Recurrent thoughts of death or a suicide attempt or plan

What is the evidence for differences in treatment response between bipolar and unipolar depression?

Moderate to low quality evidence suggests no differences in depression severity between people with bipolar or unipolar depression after treatment with antidepressants. There are small, but clinically significant effects of improved depression symptoms with any antidepressant for major depressive disorder. For bipolar disorder, the antidepressant paroxetine, antipsychotics aripiprazole, lurasidone, olanzapine, quetiapine, and ziprazidone, and mood stabilisers lithium, lamotrigine, and divalproex also have small, but clinically significant effects for improving depression.

November 2021

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Bipolar disorder is characterised by recurrent episodes of depression and mania, hypomania, or mixed symptoms. A major depressive episode is a period of at least two weeks in which a person has at least five of the following symptoms (including one of the first two): intense sadness or despair; feelings of helplessness, hopelessness or worthlessness; loss of interest in activities once enjoyed; feelings of guilt, restlessness or agitation; sleeping too little or too much; slowed speech or movements; changes in appetite; loss of energy; difficulty concentrating, remembering or making decisions; and/or thoughts of death or suicide. Long-term studies have found that depressive symptoms are usually more pervasive than mood elevation or mixed symptoms. Depressive symptoms have also been consistently associated with greatest impairments in social and occupational functioning.

What is the evidence for bipolar depression?

High quality evidence shows an earlier age of illness onset of bipolar disorder is associated with increased severity of depression. Moderate to high quality evidence shows depression episodes are around three times more common than mania, elevated, or mixed episodes over the course of bipolar disorder. Factors associated with depression predominance are; type II bipolar disorder, melancholia symptoms, a depressive onset of illness, suicide attempts, mixed episodes, and delayed diagnosis of bipolar disorder.

Moderate quality evidence suggests the factors associated with bipolar depression rather than unipolar depression in children or youth include; more psychiatric comorbidities and behavioural problems (oppositional disorder, conduct disorder, anxiety disorders, irritability, suicidal/self-harm, social impairment, and substance use); earlier onset of mood symptoms; more severe depression; and having a family history of psychiatric illness.

Moderate to low quality evidence suggests the cumulative rate of conversion from unipolar depression to bipolar disorder increases from 3.78% at 1 year assessment to 12.87% at 10 year assessment. However, the yearly rate of conversion from unipolar depression to bipolar disorder decreases from 3.83% at 1 year assessment to 0.78% at 10 year assessment.

Moderate quality evidence finds no differences in levels of anhedonia (reduced capacity for pleasure) between people with bipolar disorder and people without a mental illness. Levels of anhedonia were higher only in people with schizophrenia, major depression (not remitted), substance use, and Parkinson’s disease when compared to people without a mental illness.

September 2021

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A supplementary, or adjunctive, treatment is administered in conjunction with a patient’s ongoing antipsychotic therapy. Antidepressants have been proposed as an additional therapy to standard antipsychotic treatments, in an attempt to improve functional outcomes and treat symptoms that are not addressed by the antipsychotic medication alone. Antidepressant medications have been studied as treatments for the symptoms of schizophrenia, particularly negative symptoms, as well as for treating people with co-occurring schizophrenia and depression.

What is the evidence for adjunctive antidepressants?

Moderate quality evidence finds small effects of greater improvement in overall, negative, positive, and depressive symptoms with adjunctive antidepressants. The effect size was largest for negative symptoms and smallest for positive symptoms.

Moderate to high quality evidence finds a medium-sized effect of more smoking cessation with adjunctive bupropion than with placebo, which was maintained at six months follow-up.

Moderate quality evidence finds small benefits of adjunctive antidepressants for global cognition and executive functioning, but not for memory, attention, processing speed, verbal fluency or visuospatial processing.

September 2020

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