Chapter 14 - Depressive Disorders

Disruptive Mood Dysregulation Disorder (DMDD)

• Children & adolescents being diagnosed with bipolar disorder that did NOT go on to have bipolar symptoms

  • irritability & anger

  • temper tantrums

Diagnostic criteria for DMDD?

Pt must exhibit symptoms in at least 2 settings

Tx for DMDD?

• Antidepressants

• 2nd Gen Antipsychotics

  • Risperidone

  • Aripiprazole

Persistent Depressive Disorder

• low-level depression occurs most of the day

  • 2yrs adults

  • 1yr children/adolescent

Tx for PMS

• Drospirenone + Ethinyl Estradiol

• SSRI

  • Fluoxetine

  • Sertraline

• Diuretics

How does substance induced depression work?

Depressive symptoms remit upon withdrawal

Major Depressive Disorder

• Depressed mood lasting > 2 weeks

In children/adolescents how can depression look like?

Irritable Mood

Seasonal Depression

• Hypersomnia

• Overeating

• Craving carbohydrates

Bereavement Exclusion

Not diagnosing depression 1st 2 months following a significant loss

**Not followed anymore

Subsyndromal Depression

When older adults experience many but not all s/s of a major depressive episode

T/F: S/S of depression were improved with magic mushrooms

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Serotonin Dysfunction Manifestations

• Sleep disturbances

• Decr appetite

• Low sex drive

• Impulsivity

Diathesis Stress Model of Depression

• Interplay between genetic & biological predisposition

  • Why 2 people respond to the same event diff

Cognitive Theory

The idea that thoughts will result in emotions

• Negative interpretations = anger/hopeless

• People with depression tend to ignore the positive aspects

A suicidal pt with a plan requires what?

Immediate intervention

Anhedonia

Inability to feel pleasure

KEY SYMPTOM*

Depression Key Findings

• Anhedonia

• Exaggerate perceived faults

• Chronic pain

• Hopelessness

Anergia

Lack of energy

• Fixed gaze

• Incontinence

Vegetative S/S of Depression

• appetite loss

• sleep disturbance

  • awake at 3am & staying awake

  • over-sleeping

• sexual interest declines

Mood

• general emotional condition

• can last for extended periods of a time

  • euthymic

  • angry

  • anxious

  • euophoric

Euthymic Mood

Normal mood

Feeling & Emotions

• more specific & can come and go

  • guilt

  • hopeless

  • helpless

Physical Anhedonia

Inability to experience physical pleasure in

• Eating

• Touching

• Sex

Affect

• Outward expression

  • Congruent with mood

  • Incongruent with mood

T/F: Cognitive deficits may linger even after successful treatment

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Depression S/S in Children and Adolescents

• Suddenly refuse to go to school

• Substance use

• Sexual promiscuity

Common S/S of Depression

• giving away prized possessions

• poor problem solving

• withdrawn

• excessive seeking of reassurance

Acute Phase of Major Depression Tx

• aimed at reducing depression symptoms

• restoring function

  • hospitalization

  • medication may be started

Continuation Phase of Major Depression Tx

Preventing relapse

• meds

• education

• psychotherapy

Maintenance Phase of Major Depression Tx

Prevent further episodes

Platitudes

Overly used statements to help person “feel better”

• “everything happens for a reason”

Why should platitudes NOT be used?

They minimize the patients feelings

Tx if patient is acutely suicidal?

Electroconvulsive Therapy

Goal of antidepressants

Complete remission of symptoms

Why do patients get mood-stabilizer along with antidepressants?

Bc antidepressants can precipitate a psychotic episode

Esketamine

• FDA approved for tx-resistant depression

  • MOA: prevents glutamate from binding to NMDA receptors

1st line tx for depression?

SSRIs

In Serotonin Syndrome, what may treat hyperthermia?

Chlorpromazine (1st gen antipsychotic)

In Serotonin Syndrome, what may treat muscle rigidity?

Dantrolene

In Serotonin Syndrome, why may induction of paralysis be done?

To prevent rhabdomyolysis

What type of restaurants should pts on MAOIs avoid?

Asian

St.Johns Wort

• Increases NDS neurotransmitters, resulting in antidepressant effects

  • **potential for adverse effects

Electroconvulsive Therapy (ECT)

• Treats depressive s/s with MDD & BPD > 13yrs

Electroconvulsive Therapy (ECT) RISKS

Heart & brain stress

Electroconvulsive Therapy (ECT) Procedure

• pt given gen anesthetic to sleep

• muscle paralyzing agent is admin

• brief seizures are induced

  • confused for several hours

  • retrograde amnesia (loss of memory of events leading up to tx)

What may need to be discontinued before ECT?

Benzos as they will interfere with seizure induction

Repetitive Transcranial Magnetic Stimulation (rTMS)

• MRI strength pulses stimulate focal areas

• Indication: mildly tx-resistant depression

• Contraindications: metal in brain & history of seizure

Vagus Nerve Stimulation

• Improves mood by stimulating vagus nerve and boosting levels of neurotransmitters

• indication: tx resitant depression

• pulses delivered

• se: hoarseness

Deep Brain Stimulation (DBS)

• electrodes surgically implanted to stimulate underactive regions

• invasive but reversible