DSA10 - Depressive Disorders

Major Depressive Disorder (MDD) - SINGLE Episode

Define Condition:

FIRST episode

-Hx:

> Onset = 29 on avg

> More in FEMALES

> Lower SES

> BEREAVEMENT!

-Sx:

> Depressed Mood > 2 wks

> Loss of interest/Pleasure in ALL ACTIVITIES (ANHEDONIA)

> Five or more of these Sx in Same two week Period(change from past functioning):

>> Sleep (Insomnia/Hypersomnia)

>> Interests (less)

>> Guilt/Worry

>> Energy (less)

>> Concentration (less)

>> Appetite (More or Less)

>> Psychomotor disturbances = agitation or retardation of MOVEMENTS (ex: Anxious, Unsettled, Feeling "weight")

>> Suicidal Ideations

-Dx: PHQ-9 (Abn = 15-19)

-Tx: Antidepressants + CBT; Electro-Convulsive Therapy (ECT)

> Maintenance

>> If no S/Es or tolerability issues --> Increase dosage every 2-3 wks until Remission (continue meds 6-9 mos after remission)

-Prog:

> Recurrence after initial episode WITHOUT long-term treatment

> Co-Morbidities:

>> Stroke

>> D2M

>> CAD

>> Alzheimer's

>> Bipolar

Major Depressive Disorder (MDD) - RECURRENT

Define Condition:

AFTER First Episode (AKA SECOND AND BEYOND) - Relapsing AND Remitting

-Hx:

> Onset = 29 on avg

> More in FEMALES

> Lower SES

> BEREAVEMENT (up to 2 months, but can last from 1-2 yrs)

> One/More Previous Episodes

-Sx:

> Depressed Mood/Anhedonia > 2 wks

> Loss of interest/Pleasure in ALL ACTIVITIES (ANHEDONIA)

> Five or more of these Sx in Same two week Period(change from past functioning):

>> Sleep (Insomnia/Hypersomnia)

>> Interests (less)

>> Guilt/Worry

>> Energy (less)

>> Concentration (less)

>> Appetite (More or Less)

>> Psychomotor disturbances = agitation or retardation of MOVEMENTS (ex: Anxious, Unsettled, Feeling "weight")

>> Suicidal Ideations

-Dx: PHQ-9 (Abn = 15-19)

-Tx: Antidepressants + CBT; Electro-Convulsive Therapy (ECT)

> Maintenance

>> If no S/Es or tolerability issues --> Increase dosage every 2-3 wks until Remission (continue meds 6-9 mos after remisssion)

>> 2-3 episodes --> MAINTAINING Antidepressant (consider after 2 episodes if high risk factors for suicide, PTSD, co-morbid anxiety, chronic depression, or serious personality disorder)

> Continuation

>> Bridges remission to recovery

>> Visits every 3 month to assess efficacy and need for adjustments (increased stress)

>> Antidepressants + Psychotherapy

-Prog:

> Recurrence after initial episode WITHOUT long-term treatment

> Co-Morbidities:

>> Stroke

>> D2M

>> CAD

>> Alzheimer's

>> Bipolar

8-12 weeks (Max Dose for 4-6 weeks)

How long should Antidepressant trials last?

Persistent Depressive Disorder (fka Dysthymia)

Define Condition:

Depressed mood for MOST of the day, for more days than not + Specific Sx

-Hx:

> CHRONIC, unremitting Course

> Less severe than MDD

> Lasts > 2 years (1 yr in children/YAs)

-Sx:

> SPECIFIC TO THIS:

>> Concentration (less)

>> Hopelessness

>> Appetite (More or Less)

>> Sleep (Insomnia/Hypersomnia)

>> Energy (less)

>> Self-Esteem (LOW)

> DEPRESSION:

>> Depressed Mood

>> Loss of interest/Pleasure in ALL ACTIVITIES (ANHEDONIA)

>> Five or more of these Sx in Same two week Period (change from past functioning):

>> Sleep (Insomnia/Hypersomnia)

>> Interests (less)

>> Guilt/Worry

>> Energy (less)

>> Concentration (less)

>> Appetite (More or Less)

>> Psychomotor disturbances = agitation or retardation of MOVEMENTS (ex: Anxious, Unsettled, Feeling "weight")

>> Suicidal Ideations

-Dx:

> PHQ-9 (Abn = 15-19)

-Tx: Antidepressant

-Prog: Low chance for remission (functions through illness, but never feels well)

Risk of MANIC episode if treated for depression without close monitoring

What is the risk of treating depression WITHOUT exploring a Hx of Bipolar Disorder?

Adjustment Disorder

Define Condition:

IMMEDIATE EVENT (w/n last month) + Depressive Sx that don't match SIGECAPS + Depression/Anhedonia

-Sx:

> Depressed Mood/Anhedonia > 2 wks

> Loss of interest/Pleasure in ALL ACTIVITIES (ANHEDONIA)

> Five or more of these Sx in Same two week Period(change from past functioning):

>> Sleep (Insomnia/Hypersomnia)

>> Interests (less)

>> Guilt/Worry

>> Energy (less)

>> Concentration (less)

>> Appetite (More or Less)

>> Psychomotor disturbances = agitation or retardation of MOVEMENTS (ex: Anxious, Unsettled, Feeling "weight")

>> Suicidal Ideations

-Dx: PHQ-9 (Abn = 15-19)

-Tx: Antidepressant

Premenstrual Dysphoric Disorder (PMDD)

Define Condition:

-Hx:

> NO Depressive Sx in weeks between menses (episodic/in phases)

> At least 5 Sx must be present in FINAL WEEK before Menses Onset

-Sx:

> Depressed Mood > 2 wks

> Loss of interest/Pleasure in ALL ACTIVITIES (ANHEDONIA)

> Five or more of these Sx in Same two week Period(change from past functioning):

>> Sleep (Insomnia/Hypersomnia)

>> Interests (less)

>> Guilt/Worry

>> Energy (less)

>> Concentration (less)

>> Appetite (More or Less)

>> Psychomotor disturbances = agitation or retardation of MOVEMENTS (ex: Anxious, Unsettled, Feeling "weight")

>> Suicidal Ideations

-Dx:

> PHQ-9 (Abn = 15-19)

-Tx:

> SSRIs

> Vitamins/Minerals

> CBT

> Exercise

-Prog: Sx improve W/N FEW DAYS after Menses onset --> Minimal/Absent in wks post

Depressive Disorder Due to another Medical Condition

Define Condition:

-Hx:

◦Hypothyroidism = classic rule-out

◦Anemia

◦Diabetes

◦Heart Disease

◦Cushing Syndrome

◦Head injury, Post-CVA, Post-MI

◦Cancer of head of pancreas, brain

◦Immune Disorders AIDS, SLE

◦Alzheimer’s Disease, Parkinsonism, Huntington’s Disease

◦Epilepsy

-Sx:

> Depressed Mood > 2 wks

> Loss of interest/Pleasure in ALL ACTIVITIES (ANHEDONIA)

> Five or more of these Sx in Same two week Period(change from past functioning):

>> Sleep (Insomnia/Hypersomnia)

>> Interests (less)

>> Guilt/Worry

>> Energy (less)

>> Concentration (less)

>> Appetite (More or Less)

>> Psychomotor disturbances = agitation or retardation of MOVEMENTS (ex: Anxious, Unsettled, Feeling "weight")

>> Suicidal Ideations

-Dx:

> PHQ-9 (Abn = 15-19)

-Tx: Antidepressant

Substance/Medication-Induced Depressive Disorder

Define Condition:

-Hx: Use of...

◦Alcohol, cannabis, opiates, benzodiazepines, barbiturates, stimulants (amphetamine, cocaine), sedative hypnotics

◦Steroids (anabolic, corticosteroids)

◦Antibiotics (sulfonamides, ciprofloxin)

◦Antihypertensive (beta blockers, alpha 2 agonists, etc.)

◦Interferon alpha, interleukin 2

-Sx:

> Depressed Mood > 2 wks

> Loss of interest/Pleasure in ALL ACTIVITIES (ANHEDONIA)

> Five or more of these Sx in Same two week Period(change from past functioning):

>> Sleep (Insomnia/Hypersomnia)

>> Interests (less)

>> Guilt/Worry

>> Energy (less)

>> Concentration (less)

>> Appetite (More or Less)

>> Psychomotor disturbances = agitation or retardation of MOVEMENTS (ex: Anxious, Unsettled, Feeling "weight")

>> Suicidal Ideations

-Dx:

> PHQ-9 (Abn = 15-19)

-Decreased function of monoamines

-Need Norepinephrine (down regulates beta adrenergic receptors with resulting antidepressant effect)

-Need Serotonin (P11 protein dimer complex interacts selectively with serotonin receptor proteins to promote receptor migration to the neuronal surface.)

-Antidepressants suppress REM sleep correlating with mood improvement

What is stated according to the Biogenic Amine Theory regarding the Biological Causes of MDD?

-More HPA axis activity in MDD

-Hyper-secretion of Cortisol

-Abnormal Thyroid Function

What is stated according to the HPA Axis Theory regarding the Biological Causes of MDD?

NMDA antagonism at GABA-ergic interneurons results in a rise of glutamate in the medial prefrontal cortex which leads to an immediate activation of AMPA receptors

How might NMDA antagonism treat Depression?

Promotes neuronal survival growth (seen LESS in MDD) - SSRIs, ECT & TMS increase

How does Brain-Derived Neutrophic Factor (BDNF) related to MDD's pathogenecity?

Suicidal Behavior

Define Condition:

-Hx:

> Distal Factors = PREDISPOSING Factors/Historic/Life-long conditions

>> CAUCASIAN

>> MALE

> Acute/Proximal Factors = Recent Contributors to risk

>> MOOD DISORDER

>> COMORBID SUBSTANCE ABUSE

>> RECENTLY DISRUPTED RELATIONSHIP/ROLE

>> HX OF BEHAVIOR/SELF-INJURY

> Near-Term Precipitants Or Stressors = IMMEDIATE Stressors, WARNING SIGNS/Triggers for Act

> Protective Factors = Internal or External factors likely to INHIBIT emergence of suicidal behavior

-Sx:

> Talking about suicide or death

> Giving direct verbal cues, such as "I wish I were dead" and "I'm going to end it all"

> Giving less direct verbal cues, such as "What's the point of living?", "Soon you won't have to worry about me," and "Who cares if I'm dead, anyway?"

> Isolating self from friends and family

> Expressing the belief that life is meaningless or hopeless

> Giving away cherished possessions

> Exhibiting a sudden and unexplained improvement in mood after being depressed or withdrawn

> Neglecting appearance and hygiene

-Tx: Antidepressant

-Prog:

> READY ACCESS TO FIREARM/WEAPON --> EXTREMELY SERIOUS! (MC METHOD, esp for WHITE MALES)

> More MALES die

Serotonin Syndrome

Define Condition:

-Hx: Use of...

> SSRIs

> SNRIs

> TCAs

> MAO-Is

> Triptaks (migraines)

> Meperidine

> Fentanyl

> Ondasetron (Antiemetic)

> Linezolid (Abx)

> Dextromorphan

> St. John's Wort

> LSD/MDMA

-Sx/PE: HYPERKINETIC (compared to Neuroleptic Malignant Syndrome)

> AMS (Agitation, confusion, delirium)

> NM Changes (Clonus, Hyperreflexia)

> Autonomic Instability (Tachycardia, Mydriasis, Sweating, Fever, GI Motility/Diarrhea)

-Dx:

> Metabolic Acidosis

> Elevated Cr

> Elevated Liver Enzymes

-Tx:

> 24 hr Close Observation

> Benzos (Diazepam, Lorazepam) - decrease agitation, seizure-like movements, muscle stiffness

> Cyproheptadine - blocks Serotonin production

> IV Fluids

> Withdraw meds

> Life-Threatening = Paralytic Meds + Breathing Tube/Machine (Prevent further muscle damage)

-Prog: Seizures, shock, delirium, renal failure, rhabdomyolysis, disseminated intravascular coagulation, and death

SSRI Discontinuation Syndrome

Define Condition:

Occurs in approximately 20 percent of patients after abrupt discontinuation of an antidepressant medication that was taken for at least six weeks

-Hx: Long duration of Tx + Meds w/ Shorter half-life

-Sx/PE: Mild, 1-2 wks

> Flu-like Sx

> Insomnia

> Nausea

> Imbalance

> Sensory disturbance

> Hyperarousal

-Tx: STOPS w/ Antidepressants

Akathisia

Define Condition:

Movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion

-Hx: Use of SSRIs (Serotonergic-mediated inhibition of Dopaminergic System)

-Tx: D/C SSRI + Evaluate all contributory meds

Drug-Induced Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Define Condition:

Euvolemic Hyponatremia

-Hx: WELL KNOWN S/E of SSRIs

-Path: Loss of autoregulation of ADH --> impaired water excretion

1) Increased ADH secretion

2) Increased renal response to ADH

-Sx/PE:

> Instability

> Falls

> Reduced cognitive function

-Tx: Obtain Periodic Labs on SSRIs

-Prog:

> Osteoporosis

> Increased morbidity/mortality

Type of psychotherapy which helps a person learn to recognize negative patterns of thought/COMMON COGNITIVE DISTORTIONS, evaluate their validity, and replace the negative thought pattern with healthier ways of thinking

Define Cognitive Behavioral Therapy

Drawing specific conclusions without sufficient evidence "Hitting the ball out of bounds just proves I'm no good at golf and never will be."

Define Arbitrary Interference (Cognitive Distortion)

Focusing on a specific detail and ignoring more important information "Even though he said I looked beautiful I know he hates my nose and sees me as ugly."

Define Specific Abstraction (Cognitive Distortion)

Forming conclusions on little experience "Since I can't get along with my boss, I'm a failure and can't get along with anybody."

Define Overgeneralization (Cognitive Distortion)

Altering the significance of events to make it negative "Sure I got a good grade on the test but that doesn't matter because it was an easy test.'

Define Magnification and minimization (Cognitive Distortion)

Interpreting events as always reflecting on self. "My husband was in a bad mood when he came home from work. I must be a lousy wife and worthless person."

Define Personalization (Cognitive Distortion)

Seeing everything in an all or none framework "I got a B in this course and As in the others, which proves I'm a lousy student."

Define Dichotomous Thinking (Cognitive Distortion)

◦ Schedule – taking control by planning and organizing to counteract avolition(lack of motivation or drive)

◦ Pleasurable Activities – engaging in one pleasurable activity a day to counteract anhedonia (inability to experience joy or pleasure)

◦ Exercise – increasing activity even slightly increases sense of control and has positive physical benefits

◦ Assertiveness – engaging in small acts that set limits and express ones own feelings can reflect positively on sense of self

◦ Kind Thoughts About Oneself – positive self talk can negate effects of negative/irrational self perceptions

Define Supportive Therapy (aka identify aspects of SPEAK acronym)

◦ Understand the patient's idea of the impact of the illness - in other words what problems are created by the depression

◦ Identify social and financial barriers to adherence

◦ Decrease barriers that could arise from side effects

What are some strategies to improve pt adherence to therapy?