Depression

Describe MDD:

• Dx stats

• Mortality

• Reason for under diagnosis?

Major Depressive Disorder

• Diagnosis Stats:

  • Only 33% of depressive pts = diagnosed/treated

  • Up to 20% of pts in primary care clinics are depressed; 

    • Only half are diagnosed 

• Mortality:

  • Up to 15% if individuals die by suicide

  • Pts > 55 = 4x Mortality

• Reasons for Under Diagnosis:

  • Many present w/ somatic complaints

  • Difficult differentiate depression from normal emotional ups/downs

  • Stigma: Reasons for under-recognition

1. List the Dx criteria for MDD and Associated Symptoms (8,10)

2. When does an episode end?

Dx Criteria

• One or more Major Depressive Episodes

• Must have:

  • Depressed mood* OR Loss of interest or pleasure*

• >5 of Sig:ecaps during 2 Week Period:

  • Increased or decreased Sleep

  • Loss of Interest in activities

  • Inappropriate Guilt

  • Decreased Energy

  • Trouble Concentrating

  • Increased or decreased Appetite

  • Psychomotor agitation or retardation

  • Suicidal ideation

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Associated Symptoms of MDD:

• Tearfulness

• Irritability

• Brooding or Obsessive Rumination

• Anxiety or Phobias

• Excessive Worry over Physical Health

• Complaints of Pain

• Difficulties in Sexual Functioning

• Menstrual Problems

• Dizziness

• GI Complaints

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When does an episode end?

• considered to have ended when the full criteria for a Major Depressive episode have not been met for at least two months

Describe the mental status findings in depression

Mental Status Findings

• Alertness and Orientation

  • Usually unremarkable 

• Speech

  • normal or slowed or soft

• Mood

  • depressed or irritable

• Affect

  • normal range in mild cases, 

  • blunted or labile in severe cases

• Thought Process

  • thought blocking in severe cases

  • tangential in bipolar depression

• Thought Content

  • query for suicide ideation

  • delusions or hallucinations in severe cases

• Memory

  • impaired in severe cases (“Pseudodementia”)

• Intellect

  • not impacted

• Judgment for self-preservation

  • impaired in moderate to severe cases (“Nothing matters”)

  • passive wish for death 

• Insight

  • intact in mild cases; impaired in severe

Describe the relationship between cognitive problems and depression

Cognitive problems in depression

• Depression filter distorts normal perceptions and memories

  • -> dramatically affect mood and feelings of self-worth

Describe Self Esteem

• What is it?

• Purpose

• High vs Low

  • History

  • Reality

• Effect of low

Self Esteem

• What is self-esteem?

  • How positively person feels about themselves

  • Eval. of the self

• Purpose of Self Esteem:

  • helps us monitor our social worlds for indications that we might be rejected and motivates us to make ourselves acceptable to other people

• High vs Low Self Esteem:

  • History:

    • High: history of primarily acceptance

    • Low: history of neglect, disinterest, or rejection

  • Reality:

    • Most people who are considered to have “low self-esteem” actually have a midline view of themselves

• Effect of Low Self Esteem:

  • Low -> negative emotions -> rejection 

    • People function best w/ realistic view of strengths/weaknesses

    • Therapy: improves social live quality -> have adequate supportive relationships

List the Psychosocial Effects of Depression (3)

Psychosocial Effects

• Difficulty in intimate relationships and marital problems

  • Less satisfying social interactions

  • Difficulties in sexual functioning

• Occupational problems

  • Loss of job

  • Absenteeism/Presenteeism

• Academic problems

  • Truancy

  • School failure

  • Underachievement

Describe the Course of MDD:

• Course

• Effect of Remission and future recurrence:

• Prognosis

Describe the Effects of Depression on:

• Glucocorticoids

• Sleep (5)

• Other Hormones? (3)

Course and Duration

• Course:

  • Dev. over days/weeks -> (untreated) lasts up to >6 months

• Effect of Remission and future recurrence:

  • First episode: 50-60% likelihood of recurrence

    • 5-10% = manic episode later

  • Second: 70%

  • Third: 90%

• NOTE: 

  • Periods of remission longer early in course

  • Psychosocial factors play a greater role in precipitating first/second episode

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Prognosis (1 yr after diagnosis)

• 40% no mood disorder

• 20% do not meet criteria for MDD

• 40% still meet criteria for MDD

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Associated Laboratory Findings

• Elevated glucocorticoid levels + EEG Sleep disturbances  (MDD or w/ psychotic features) 

  • Elevated Glucocorticoids:

    • Elevated urinary free cortisol levels

    • Dexamethasone nonsuppression of plama cortisol

  • Sleep Findings:

    • Prolonged sleep latency

    • Increased wakefulness

    • Early morning awakening

    • Reduced stage 3/4 (slow wave) sleep

    • Decreased REM latency and increased early REM sleep

• Blunted growth hormone, TSH and prolactin responses

Describe Sick Behavior:

• What does Depression cause activation of? Consequence of this?

• What are normal ways of activating this?

What are other conditions w/ high rates of depression (7)

“Sick behavior” (SB)

• Depressive symptoms  -> Microglia activation 

  • inflammatory cytokines -> impaired synaptic plasticity -> neuronal dysfunction and mental disorders

• Other Activation of Microglial

  • Cytokines crossing leaky BBB

  • Afferent vagal nerve

  • Increased levels of glutamate associated with exposure to acute stress

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Conditions with High Rates of Depression

• Thyroid disease

• Cancer

• CV disease

• Stroke

• Autoimmune and inflammatory disorders

• Huntington’s, Parkinson’s, MS

• COPD

Describe the link of depression and painful physical symptoms

Describe the relationship of Depression on:

• Diabetes

  • Why does this happen? (5)

• Hypertension

• Arthritis

  • Symptomatic Effects? (4)

Give examples of Depression Hindering Self-Management of Medical Illness

Depression and Diabetes

• Depression =  increased risk of diabetes 

  • (~15-20%)

  • Greater risk if on antidepressants

    •  (~25%)

• Diabetes = increased risk of Depression:

  • (~25-30%)

  • Greater risk if on insulin

    • (~>50%)

• Reasoning why

  • Daily diabetes management is stressful

  • Depression -> interfere w/ Diabetes Management (BS monitoring +good diet)

  • Poorly controlled diabetes -> symptoms that mimics MDD

  • PTs feel conflicts w/ physician b/c of complications + difficulty controlling BS

  • Thus, Common denominator = stress hormone levels (cortisol)

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Depression and Hypertension

• Depression -> increased risk of hypertension 

  • 1.4-1.8 x

• Anxiety -> increased risk of hypertension 

  • 1.8 x

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Depression and Arthritis

• Depression -> decreased remission

  • 41% vs 57% for rheumatoid arthritis

  • 18% vs 38% for psoriatic arthritis

• Symptomatic Effects (depression/anxiety)

  • higher tender joint count, 

  • worse general health, 

  • more pain, 

  • slightly elevated inflammation markers

• NOTE: The presence of anxiety without depression did not have a statistically significant effect, though those with anxiety did numerically worse.

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Depression Hinders Self-Management of Medical Illness

• Depressed smokers 40% less likely to quit smoking

• Depressed coronary artery disease patients less likely to adhere to low-dose aspirin therapy

• Depressed post-MI patients more likely to drop out of exercise programs

Describe the Adverse Effects of Depressive Symptoms on Health for:

• Post CABG (3)

• HIV (3)

• Hep C (1)

• Overall Health (3)

Adverse Effects of Depressive Symptoms on Health

• In Women after CABG:

  • Reduced NK Activity 

  • more all-cause infections 

  • more self-reported illnesses

• HIV:

  • Negatively affects progression

    • Decreased CD4 T lymphocytes, 

    • increases in viral load, 

    • greater risk for clinical decline and mortality

• hepatitis C virus

  • More depressive symptoms during IF N-alpha treatment -> less likely to clear

• Overall health:

  • Decrements in adaptive immune measures

  • Increased mortality in nursing facility

  • Worsens mortality post-stroke

1. Describe the Gender Differences in Co-morbidities with Depression

2. DDx

Gender Differences in Co-morbidities with Depression

• More Common in Men

  • Alcohol Use disorders

  • Other substance use disorders

    • Stimulant

    • Cannibas

    • Hallucinongen

• More Common in Women

  • Panic disorder

  • GAD

  • Social phobia

  • Bulimia

  • Thyroid disease

  • Migraine

  • Fibromyalgia

  • Chronic fatigue syndrome

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DDx of Depression

• Bipolar disorder, depressive phase

• Anxiety disorders

• Effects of substance use

• Medical conditions

• Dementia (elderly)

• Schizophrenia (negative symptoms)

• Bereavement

Describe the relationship between Depression and Long-term Brain Injury:

Depression and Long-term Brain Injury:

• Prolonged depression ->

  • Progressive/cumulative damage to brain

  • Predisposition to chronicity or recurrence

• Challenges traditional view that depression = fully reversible

Describe SAD

• What is it?

• Course

• Symptoms (4)

• Geology

• Tx

Seasonal Affective Disorder [SAD]

• What is it?

  • MDD + “With Seasonal Pattern”

• Course:

  • Symptoms emerges in  fall and winter 

    • Also summer

• Symptoms:

  • Lethargy, fatigue, hypersomnia, overeating 

    • Others may present 

• Geology:

  • More common in northern latitudes (light deprivation)

• Tx:

  • Standard therapy + light therapy

Describe Persistent Depressive Disorder (Dysthymia)

• What is it? (6)

  • MEMTIP?

• What is it NOT?

• AKA?

• Lifetime Prevalence?

• Course

Persistent Depressive Disorder (Dysthymia)

• What is it?

  • Depressed mood most of the time for >2 yrs; W/ two of following: MEMTIP: lets play A game of CHESS

    • Increased/decreased appetite

    • poor concentration or difficulty making decisions,

    • feelings of hopelessness

    • low energy

    • in/hypersomnia

    • low self-esteem,

  • Not w/o symptoms for more than 2 months w/in this period

• What is it NOT?

  • NO MDD during two years

    • Could have MDD only if it ended in remission

• AKA:

  • Called in past: “Depressive Neurosis”

• Lifetime Prevalence:

  • Women: 4.1%

  • Men: 2.2%

• Course: Two groups:

  • Those who have depressive symptoms since childhood or late adolescence

  • Healthy pts -> major losses -> demoralization

  • 10% each year will develop MDD

Describe Disruptive Mood Dysregulation Disorder

• What is it?

• Dx Criteria

Disruptive Mood Dysregulation Disorder

• What is it?

  • Severe recurrent temper outbursts (verbal/behaviorally) 

    • Out or proportion/duration

    • Inconsistent with developmental level

    • On average, 3 or more times per week

  • Mood between outburst = persistently irritable or angry

• Dx Criteria:

  • Symptoms present 12 or more months, without a period of 3 months or more w/o symptoms

  • Diagnosis should not be made the first time before the age of 6 or after the age of 18.

  • Age of onset of symptoms should be before 10.

Describe Premenstrual Dysphoric Disorder

• Course

• Symptoms (4)

• Associated symptoms

Course:

• Symptoms present:

  • final week before onset

  • improve within a few days after onset

  • minimal/absent post menses 

• Symptoms occur in most menstrual cycles over prev. year

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Symptoms (one or more):

• affective lability

• irritability or anger or increased interpersonal conflicts

• depressed mood, feelings of hopelessness, or self- deprecating thoughts

• anxiety, tension, and/or feelings of being keyed up or on edge

---

Associated Symptoms (one or more present w/ symptoms above):

• Decreased interest in usual activities

• Difficulty concentrating

• Lethargy or fatigue

• Change in appetite

• Hypersomnia or insomnia

• Feeling overwhelmed

• Physical symptoms such as breast tenderness or swelling, joint or muscle pain,

• bloating or weight gain

Describe Other Specified Depressive Disorder

• Dx criteria

Describe these NOS:

• Minor depressive disorder

• recurrent brief depressive disorder

• Postpsychotic depressive disorder of schizophrenia

Dx Criteria:

• Symptoms do not meet criteria for other mood disorders

• Recurrent Brief + short duration

  • (2-13 days per month for at least 12 months)

  • (episode of 4-13 days duration)

• Insufficient symptoms

  • (episode of 14 or more days with depressed mood and at least one other symptom)

---

NOS:

• Minor depressive disorder

  • Episodes of at least two weeks of symptoms but < 5 symptoms of MDD

• Recurrent brief depressive disorder

  • Depressive episodes lasting from 2 to 14 days at least once a month for twelve months

• Postpsychotic depressive disorder of schizophrenia

  • major depressive episode that occurs during residual phase of schizophrenia

How do you manage depression

Management of Depression

• Establish optimistic tone in initial interview

• Assess severity of symptoms

• Avoid extensive psychological “probing” when the patient is deeply depressed

• Assess and reassess risk of suicide

• Mild depression: 

  • psychotherapy or somatic therapy (Antidepressant medication, ECT, TMS)

• Moderate to severe depression: 

  • somatic therapy +/- psychotherapy

Draw out the clinical stages in treatment of MDD

Describe APA Treatment Guidelines

• Acute Phase

• Cont. Phase

• Maintenance Phase

Describe Treatment Outcomes for Depression

• What does Response mean

• Describe Remission?

  • What is it?

  • STATS

• What are the Risks of Not Achieving Remission

APA Treatment Guidelines

• Acute phase (Months 1–2)

  • Goal: 

    • achieve remission

    • Restore baseline level of symptomatology and functioning

• Continuation phase (Months 2–6+)

  • Goal: 

    • prevent relapse of episode

  • Medication dose that achieved remission should generally be used in this phase

• Maintenance phase (Months 6+)

  • Goal:

    • prevent recurrence of new episode

  • Tx depends on clinical condition of patient

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Treatment Outcomes for Depression

• Response:

  • Clinically significant reduction in baseline symptom severity

  • 50% or greater reduction in HAMD-17

• Remission:

  • What is it:

    • Absence or near absence of symptoms

    • Return to “functional normality” 

      • (not just feeling better)

    • Pts can’t be distinguished from those w/o depression

  • STATs:

    • <50% of pts achieve this 

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Risks of Not Achieving Remission

• Greater risk of relapse/recurrence

• More chronic depressive episodes

• Shorter durations between episodes

• Continued impairment in work and relationships

• Increases Mortality of Everything

Describe Depressed patient’s response to physician and the consequence of that

Depressed patient’s response to physician

• Guilt: expectation of being criticized or punished

  • May underreporting symptoms -> not be complainer

• Anger: feel rejected

  • struggle against perceived mistreatment

  • verbalized disappointment at prior clinicians inability to treat symptoms

  • elicit helpless feeling in physician

• Dependent

  • Hoping for rescue, but believing physician powerless

  • May elicit “rescue” fantasy in physician