10/12 Mood Disorders: Depression - Palmeri Flashcards
mood disorders
- illnesses marked primarily by disturbances in mood (persistent emotional state)
- elevated (manic) or depressed
- always see impairment in occupational/social/other areas of fx
- not attributable to effects of a substance, another med/psych condition
primary symptom : mood change
addtl symptoms almost always occur in sleep/appetite/cognition/behavior
depressive disorders
- disruptive mood dysregulation disorder
- major depressive disorder
- persistent depressive disorder
- premenstrual dysphoric disorder
- substance/medication-induced depressive disorder
- depressive disorder due to other med cond
- other specified or unspecified depressive disorder
disruptive mood dysregulation disorder
features
duration, specifications
onset/dx/ddx
comorbidity
severe, recurrent temper outbursts (verbal and behavioral) that are grossly out of proportion in intensity and duration
- inconsistent with developmental level
- occur 3+ times weekly
- between outbursts: irritable or anger most of the day on most days
- 12+ months
- in at least 2/3 settings (home, school, with peers)
- severe in at least one setting
often severe disruption in family/peer/school activities
onset before age 10, diagnosis between 7-18
ddx: bipolar, major depression, substance induced, others
comorbidity high esp with oppositional/defiant disorder
major depressive disorder
5 or more symptoms for at least 2 weeks, nearly every day
- ONE SX MUST BE either depressed mood or anhedonia (loss of interest/pleasure) for almost every day in that period
other sx can be:
- at least 5% change in body weight with wt loss, wt gain, change in app
- insomnia/hypersomnia
- psychomotor agitation/retardation
- fatigue/loss of energy
- feelings of worthlessness/guilt
- cognitive symptoms
- recurrent thoughts of death/SI
depression acronym
SIG E CAPS
S - sleep disturbance
I - loss of interest in usual activities
G - guilt/worthlessness
E - loss of energy
C - changes in concentration
A - changes in appetite/weight
P - psychomotor changes
S - suicidal thoughts
major depression clinical features
NOT sadness
- 66% contemplate suicide, 10-15% follow through
- anxiety is common
- many physical sx
- kids: more behavioral difficulty
depression epidemiology
course of illness
lifetime prevalence 13-20%
- 18-29 rate 3x as high as 60+ rate
- 2-3x more common in women than men
course: remitting vs chronic
- recovery within 1yr for 4/5 patients
- chronic MDD for 1/5
- risk of chronicity increases wit anx, personality disorders, psychosis, and substances
- also incr with severity of first episode, younger populations, prev multiple episodes
may be present as first episode of eventual bipolar or schizophrenic disorders
major depression risk and prognosis
negative affectivity
adverse childhood experiences
substance abuse, anxiety, borderline personality, chronic medical conditions incr risk
heritability 40%
- 1st degree family members? 2-4x higher risk than genpop
major depression ddx
medical disorders
- drug intoxication/withdrawal
- tumors
- infections
- cerebrovascular, CV events
- metabolic, endocrinological, nutritional disturbances
- neurological illnesses
psych illnesses
- substance abuse
- anx disorders
NOT SADNESS
MDD
course and prognosis
first episode occurs before 40 in half of patients
untreated? 6-13 months
5-10% of initial MDD diagnoses → manic episodes
recurring illness
- 25% in 6mo
- 30-50% in 2yr
- 5–75% in 5yr
MDD etiology
neurobiological correlates
multifactorial interplay of physiologic, psychological, social factors
neurobio correlates
- genetic features
- monoamine dysfx
- HPA axis
- alteration in sleep
- link between brain/emotions
- nt dysfx
MDD sleep abnormalities
- delayed sleep onset
- shortened REM latency
- longer initial REM period
- abnormal delta sleep (long wave sleep)
MDD psychological etiologies
life events and environmental stressors can alter fx state of neurotransmitters and structure of brain
- personality factors (perfectionism) and temperamental factors (sensitivity) → predisposed to sense of loss
- interal conflicts re: aggression/love/sense of self → predisposing
MDD psychological factors
dysfunctional thought patters and beliefs about oneself, environment, future → painful affects, dysfxnl behavior, expectation of failure
- can predispose to depression
loss of interpersonal connections and efficacy → perpetuate depression
MDD social etiologies
- occupational and financial stressors
- lack of social supports
- physical health status
- role of spirituality/organized religion
selected specifiers for MDD
subsets of depression:
with anxious distress
- feeling keyed up/tense
- feeling restless
- difficulty concentration (due to worry)
- fear that something awful will happen
- feeling that pt might lose control of self
selected specifiers for MDD
subsets of depression:
with melancholic features
either:
- loss of pleasure in all/almost all activities
- lack of reactivity to pleasurable activities
AND
3 or more of the following:
- profound despondency
- depression worse in morning
- EMA (early morning awakening)
- psychomotor agitation/retardation
- anorexia and wt loss
- excessive/inapprop guilt
selected specifiers for MDD
subsets of depression:
with melancholic features
either:
- loss of pleasure in all/almost all activities
- lack of reactivity to pleasurable activities
AND
3 or more of the following:
- profound despondency
- depression worse in morning
- EMA (early morning awakening)
- psychomotor agitation/retardation
- anorexia and wt loss
- excessive/inapprop guilt
selected specifiers for MDD
subsets of depression:
with atypical features
- mood reactivity
AND
2 or more of the following:
- significant weight gain or increase in appetite
- hypersomnia
- leaden paralysis
- interpersonal rejection sensitivity
selected specifiers for MDD
subsets of depression:
with psychotic features
- delusions and hallucinations
- mood congruent (punishment, guilt)
- mood incongruent (atypical)
selected specifiers for MDD
subsets of depression:
with peri partum onset
sx occur during pregnancy or in 4 weeks following delivery WITH OR WITHOUT PSYCHOSIS
may be more common in first pregnancy
pt presenting with psychotic ft more likely with second episode or history of MDD or bipolar
selected specifiers for MDD
subsets of depression:
with seasonal pattern
regular relationship with onset of dep and time of year (fall/winter)
- full remission or switch to hypomania/mania occurs at characteristic time
over lifetime, should display more seasonal than non-seasonal depressions
persistent depressive disorder
depressed mood most of the day for more days than not for at least 2 years
two or more of the following while dep:
- appetite change
- sleep change
- low energy
- low self esteem
- poor concentration
- feelings of hopelessness
never without symptoms during those two years for more than two months
5-6% of genpop, more common in women
lots of comorbidity
onset: early
risk/prognostic factors:
- negative affectivity
- substance abuse
- conduct disorder
- parental loss or separation
persistent depressive disorder
etiology
biological
- decreased REM latency
psychosocial factors
- vulnerability of patients with certain personaly traits
- abnormal thoughts → sense of helplessness, poor interpersonal relationships → depressed mood
persistent depressive disorder
course and prognosis
ddx: “double depression” (PDD + MDD event on top of it), substance abuse/dependence, personality disorders
about 50% of pt have sx before 25
- 20% progress to MDD
- 15% progress to bipolar II
- 5% progress to bipolar I
treatment helps, but 25% never attain remission
premenstrual dysphoric depressive disorder
five sx must be present in final week before onset of menses and IMPROVE within a few days after onset of menses and BECOME MINIMAL in week after menses
- marked affective lability
- irritability or interpersonal conflict
- depressed mood
- tension/anx
- decr interest in usual activities
- difficulty concentrating
- lethargy
- chagne in appetite
- change in sleep
- sense of being out of control/overwhelmed
- physical sx
confirmed through two cycles of prospective daily rating, present through most of last year
onset after menarche, often worse near menopause
risk factors: stres, previous trauma, seasonal changes
potentially up to 50% heritability
OCP may lessen sx
premenstrual dysphoric depressive disorder
treatment
- mood charts
- monitor caffeine, sugar, sodium
- exercise
- calcium, B6
- light therapy
- cognitive behavioral therapy
- SSRIs
substance/medication induced depressive disorder
prominent and persistent disturbance in mood which predominates clinical picture
AND
sx occur soon after intox/withdrawal/exposure to a sub/medication (within a month)
AND
substance/med is capable of producing mood changes
- mood disturbance is not related to depressive disorder or delirium
depressive disorder due to another medical condition
prominent and persistent depressed mod or decr interest that dominates clinical picture
- direct pathophys effect of another medical condition
- IS NOT DELIRIUM
associations with CVA (cerebrovasc accident), Huntington’s, Parkinson’s, TBI, Cushing’s, hypothyroidism
ddx: all other depressive disorders, medication-induced or adjustment disorders
major depression
treatments
- psychoparmacological
- psychotherapeutic
- electroconvulsive tx
- phototherapy
- transcranial magnetic stimulation
three phases of treatment
- acute: 4-8wk → induce remission
- continuation: 6-12mo → preserve remission
- maintenance: indicated for pt with at least 2 prev depression → avoid recurrence
MDD treatment options
meds vs therapy
pharma
- moderate-severe sx
- sleep/appetite disturbances
psychotx
- motivated pt with mild-mod sx and interpersonal psychosocial stressors
combined
- for pt who incomplete responds to either pharma or psycho
positive predictors for antidepressant response
- vegetative sx
- diurnal mood variation
- psychomotor sx
- acute onset
- family history
- lack of hypochondriacal sx
- sensitivity to side effects
guidelines for choosing medication to treat depression
basics: patient prefs, age, past hx, sx severity, side effect profile, cost
- all antideps are similarly effective and safe, so comorbid conditions and side effect profiles important to consider
- all antideps equally effective in preventing relapse and recurrence as well
PK: all antideps require a 4-8wk response time!
- requires careful monitoring
- elderly patient doses are titrated more slowly to lower overall dose level
only about 50% of patients response to first med trial
10% will be tx resistant
types of psychotherapy
1. interpersonal therapy : relationships can either promote or protect form depression
- issues with disputes, transitions, grief addressed
2. cognitive therapy (acute vs chronic illness) : how we think about ourselves and world dictates feelings and behavior
3. behavioral therapy : counteracts depression with behavioral changes → incr positive reinforcement
electroconvulsive tx
features
indications
contraindications
side effects
- efficacy superior to antidepressants
- 8-12 treatments in a series
- usually unilateral electrode
- tx effect related to length of seizure
indicated when see resistance to other treatment
- depression with psychotic ft
- acute mania
- catatonia
- severe depression/mania in pregnancy
- schizophrenia
- neuroleptic malignant syndrome
- infreq used as first line tx
contraindications: none absolute, BUT be careful with space occupying lesions!
side effects:
- anterograde amnesia for variable pd of time
- confusion
- some retrograde amnesia
transcranial magnetic stimulation
allowed by FDA since 2008
no evidence that it’s effective in patients who havent been tried on an antidep
no studies in patients with resistant depression
deep brain stimulation
studied in Parkinson’s, major depression, Tourette’s
small studies → some efficacy in depression
lots of ongoing research
