LEC 6: DEPRESSIVE DISORDERS

what age group is depression the highest & lowest among?

highest: 18-24

lowest: >65

what gender is depression higher among?

W>M

what race is depression higher among?

non-hispanic whites

are people with depression more likely to be more or less educated?

less than a high school education

what are symptoms common to each depressive disorder?

sad, empty or irritable mood accompanied by somatic or cognitive changes that affect an individuals capacity to fxn

what are the s/sx of persistent depressive disorder?

duration: @ least 2 years (not w/o sx for >2 mo)

-depressed mood PLUS 2 or more of the following:

ACHESS

what are the ACHESS?

appetite disturbance (inc or dec)

concentration/decision making difficulty

hopelessness

energy low/fatigue

sleep disturbance (insomnia or hypersomnia)

self esteem (low)

what screening tool is used for persistent depressive disorder?

PHQ-9 or PHQ2 (briefer) & beck depression inventory for primary care

what is the medical tx of persistent depressive disorder?

SSRI, SNRI, bupropion

what is the psychotherapy tx of persistent depressive disorder?

CBT or interpersonal therapy

what is the criteria for PMDD?

1 of the following that repeatedly occurs during premenstrual phase & remits around onset of menses:

-mood lability

-irritability/anger

-dysphoria

-anxiety

AND

1+ of the following (totaling 5):

-dec interest in activities

-difficulty concentrating

-lethargy/fatigue

-marked change in appetite

-hypersomnia/insomnia

-sense of being overwhelmed/out of control

-physical sx

what does confirmation of provisional dx of PMDD require?

daily prospective symptom ratings for at least 2 somatic cycles

what is the morbidity & mortality of MDD?

pt's w/ depression die 5-10 years earlier (pt's w/ bipolar die 10-20 yrs earlier)

what is the average duration of an untx episode of MDD?

3-12 months (50% affected will have a 2nd episode)

what are the comorbidities of MDD?

parkinsons, diabetes, stroke, cancer, RA, myocardial infarction, inpatients, outpatients

what is the main difficulty in diagnosing MDD?

presenting complaints are often somatic rather than psychological (significant majority only present w/ physical complaints)

what is a simple screening question that can be used to ID hidden psychiatric diagnoses & should be asked of all patients w/ unexplained medical symptoms?

have you felt depressed or sad much of the time in the past year?

what does the PHQ-9 screen for?

diagnosing & monitoring & measuring severity of depression and the presence and duration of suicide ideation

what is the criteria for MDD?

5 or more of the following in the same 2 week period; @ least 2 symptom must be 1 or 2:

1. depressed mood

OR

2. loss of interest or pleasure in most activities (anhedonia)

- significant weight loss/gain

-insomnia/hypersomnia nearly every day

-psychomotor agitation/retardation

-fatigue/loss of energy

-feelings of worthlessness/excessive guilt

-indecisiveness/inability to concentrate

-recurrent thoughts of death or suicidal ideation

what is the mnemonic for MDD criteria?

SIG E CAPS

Sleep disturbance

Interest

Guilt

Energy

Concentration

Appetite

Psychomotor

Suicidal ideation

what is seasonal affective disorder (SAD)?

major depressive disorder w/ seasonal pattern (need to meet the criteria for MDD)

what is SAD linked to?

biochemical imbalance in the brain prompted by shorter daylight hours and less sunlight in the winter

how can SAD be tx?

light therapy, antidepressant meds, talk therapy or some combo of these; also improved by change of season

what are the symptoms of MDD w/peripartum onset?

lack of interest in baby, not feeling bonded to baby, feeling very anxious about/around the baby, feelings of being a bad mother, fearing or harming the baby or oneself

how do we screen for MDD w/ peripartum onset?

depression screening for pregnant and postpartum women

what 2 neurotransmitters are involved in MDD?

norepinephrine & serotonin

what does norepinephrine do?

associated w/ arousal, vigilance, and facilitates responses to novel and stressful situations

what does serotonin do?

associated w/ satiety when basic needs are satisfied (promotes dec aggression, lowered impulsivity, & more stable emotional responses)

what is the psychotherapy tx of MDD?

equally as effective as meds;

cognitive-behavioral therapy, behavioral activation, interpersonal psychotherapy

what is behavioral activation?

getting clients, such as those who are depressed, to participate in reinforcing activities (engage in behavior & encourage them to have a thought about it & report back)

what is the medical tx of MDD?

single antidepressants: SSRIs, SNRIs, Bupropion

what are the adverse side effects of antidepressants?

sexual dysfxn, GI, sleep & weight disturbance (tell pt it will go away & tx w/ over the counter meds)

what is the tx for severe MDD?

electroconvulsive therapy (ECT)

when is ECT used?

when rapid effects are required bc of severe suicide risk, medication AEs cant be tolerated, multiple med trials have proven ineffective, or psychotic features complicate the depression

what is the only absolute contraindication to ECT?

intracranial mass

what are the potential AEs of ECT?

nausea, HA, myalgia, prolonged seizures, status epilepticus, and cardiac events

what are some potential tx for unipolar depression?

transcranial magnetic stimulation, vagus nerve stimulation, ketamine, & deep brain stimulation

what is the leading cause of death in the world?

suicide

why is suicide not considered a mental disorder?

bc it is linked to depresssion & ~1/2 of all suicides result from other mental disorders or involve no clear mental disorders at all

who is more likely to die by suicide?

men (3.6x more likely) & men who own handguns are 8x more likely (women who own guns are 35x more likely than women who dont)

what race is the rate of suicide more common in?

white americans & native americans

what are common triggers of suicide?

stressful events, mood and thought changes, alcohol and other drug use, mental disorders, and modeling

what are some long term stressors?

serious illness, abusive environments, occupational stress

who is the rate of suicide increasing more rapidly in?

adolescents (most have some type of mental health disorder)

who is more likely to die by suicide in western society?

elderly (more than any other age group)

why are the elderly more likely to die by suicide in western society?

illness, loss of close friends/family, loss of control over one's life, loss of social status

how do we evaluate suicide risk?

-elicit presence/absence of suicidal ideation, plan, & intent

-availability of means, assessment of lethality

-ID current psychosocial situations (significant stressors) and nature of crisis

-psychotic symptoms (hallucinations) or severe anxiety

-alc/substance use

-history/seriousness of prior attempts

-FHx or recent exposure to suicide

what is the goal of CBT for depression?

to alter behaviors, negative automatic thoughts and dysfunctional beliefs

what is the MOA of SSRIs?

inhibit reuptake of serotonin; preferred meds bc they have fewer AEs

what is the MOA of SNRIs?

good choice for medically ill pt's esp w/pain; few drug interactions & have higher efficacy than single action agents

what is the MOA of MAOIs?

serotonin, norepi, dopamine

what are the warnings of taking MAOIs?

HTN crisis, including death from dietary tyramine; serotonergic crisis

what is the MOA of tricyclics?

inc levels of norepi & serotonin & block action of acetylcholine

what is the MOA of bupropion?

norepi-dopamine reuptake inhibition; 1ST LINE in depressed patients who need activation; NARROW TI

what are the side effects of bupropion?

tremors, diaphoresis, anxiety, tachycardia

what can bupropion help relieve?

sexual dysfunction caused by inc serotonergic transmission (from SSRIs)

what else is bupropion used for?

smoking cessation

what increases the morbidity of diabetes?

MDD; worsens glucose control, promotes inactivity and obesity, makes it more difficult to follow diabetic care regimens

what are the antidepressants of choice for diabetes?

SSRIs

what meds should not be used in patients with diabetes and depression?

antidepressants that inc norepi (wellbutrin, SNRI) --> worsen glu control

&

MAOIs should be avoided--> risk severe hypoglycemia

what types of strokes are most frequently associated w/ depression?

strokes of the frontal lobes (esp left) & basal ganglia

what is the most freq neuropsych consequence of stroke?

post-stroke depression (impairs recovery & inc mortality)

what meds are most effective in treating depression in stroke patients?

SSRIs & SNRIs

what meds can be dangerous in tx of stroke pt/s w/ depression?

bupropion bc it lowers the seizure threshold

what does depression predict the development of?

heart disease

what meds are prescribed to cardiac pt's w/ depression?

SSRIs

what meds should be avoided in cardiac pts w/ depression?

tricyclics: significant cardiotoxic effects & lethal in overdose

MAOIs & trazodone: can cause postural hypotension

what other conditions can lead to depression?

neuropathic pain

what is the tx of neuropathic pain w/ depression?

SNRIs (ex: cymbalta) as well as tricyclics & anticonvulsants (gabapentin)

what is depression a common comorbidity to?

cancer cases

what are the RFs for depression in cancer?

history of affective disorder or alc dependence, advanced stage of cancer, inc physical impairment, pancreatic ca, poorly controlled pain

what tx should be considered in CA patients w/ depression?

SSRIs & SNRIs (can use the side effects to our advantage)

what type of psychotherapy is useful for CA patients w/ depression?

CBT!, coping & problem solving skills, relaxation skills and ways to lower stress, giving and accepting social support

what needs to be completed by every patient who agrees communication among care providers to ensure effective coordination of care?

release of information