25 - Disorders of Mood Flashcards
How common is major depressive disorder (MDD)?
- Second most common condition seen in primary care (after hypertension)
- 1/10 adult primary care outpatients have major depression or dysthymia
Describe the risk of relatives of patients with major depressive disorder (MDD) to develop MDD or other psychiatric diseases
- 1st degree relatives of individuals with MDD are 1.5-3 times more likely to also have the disorder than the general population
- 1st degree relatives also have elevated risk of alcohol dependence
- Children of individuals with MDD may have an increased risk of anxiety disorders and attention-deficit/hyperactivity disorder
What are the physical findings associated with MDD?
No laboratory findings have been identified that are diagnostic of MDD (although certain laboratory findings are more commonly abnormal among individuals currently experiencing a major depressive episode)
Describe the pathophysiology of MDD
Pathophysiology
- Dysregulation of several neurotransmitter systems
- Alterations of multiple neuropeptides
- Hormone disturbances may be present
- Alterations in cerebral blood flow may be present
- Not all individuals with MDD have these findings, and the findings are not specific to MDD
It is not as subjective as you might think - a lot of other systems are diagnosed pretty subjectively too
What are the DSM-V diagnostic criteria for a major depressive episode?
For at least two weeks, five or more of these symptoms, at least one of which is depressed mood or loss of interest/pleasure:
- Depressed mood most of the time, most days
- Loss of interest or pleasure in activities, most of the time, most days
- Significant change in appetite or weight
- Significant change in sleeping habits
- Psychomotor agitation or retardation
- Fatigue or loss of energy, most of the time, most days
- Feelings of worthlessness or excessive guilt
- Diminished ability to concentrate or make decisions
- Recurrent thoughts of death or suicide
Describe the gender differences in MDD
Women twice as likely to experience a depressive episode
- Lifetime risk for women is 10-25% in community samples
- Lifetime risk for men is 5-12% in community samples
Differential risk not evident in pre-pubertal children ***
- Just as common in adolescent male and female
Most other psychiatric diseases are the same across genders
Describe the course of MDD
- Average age of onset mid-20s, but may begin at any age
- Unlike with most anxiety disorders, course of MDD tends to be episodic
- Untreated episodes typically last at least four months, but will typically (60-75% of the time) eventually remit spontaneously
Describe the statistics on the outcome of MDD
- 40% of individuals with an MDE will still meet full criteria a year later
- 5-10% of individuals meet full criteria for an MDE lasting 2 years or more
- 20-30% of individuals will experience some symptom relief but have some symptoms persist for months or years that are still sufficient to cause clinically significant distress
- 40% of individuals who have a single MDE never have another one; risk of subsequent episodes rises with each additional MDE
- 5-10% of individuals with an MDE later have a manic episode
- 1st and 2nd episodes are more likely to be preceded by a psychosocial stressor
What is on the differential diagnosis list when diagnosing MDD?
- Normal sadness
- Grief
- Adjustment Disorder with Depressed Mood
- Persistent Depressive Disorder (Dysthymia)
- Manic episode with irritable mood or mixed features
- Dementia
- Mood Disorder Due to a General Medical Condition
- Substance-Induced Mood Disorder
What is the first line of treatment for MDD?
Psychopharmacology and psychotherapy are primary treatments
1st course of treatment only effective 40-60% of the time; multiple treatments may need to be tried.
What are the other treatment options for MDD?
- Complimentary and Alternative Medicine (CAM)
- Electroconvulsive therapy (ECT) is sometimes used in treatment-refractory depression
- Transcranial Magnetic Stimulation (TMS)
- Vagal Nerve Stimulation & Deep Brain Stimulation
- Exercise has been found to be of significant benefit in some studies
- Good sleep and nutritional habits can also be of significant benefit
- Encourage use of social support
What do you need to do before beginning treatment?
- Rule out medical causes for the mood disturbance
- Establish a diagnosis
- Assess substance use
- Assess for manic and psychotic symptoms
- Determine patient preference and past treatment outcomes
- Assess suicidality
What are the options for pharmacological anti-depressants?
- Monoamine oxidase inhibitors (MAOIs)
- Tricyclic antidepressants
- Selective serotonin reuptake inhibitors (SSRIs)
- Serotonin norepinephrine reuptake inhibitors (SNRIs)
- Others
Describe monoamine oxidase inhibitors (MAOIs)
Monoamine oxidase inhibiters (MAOIs)
- First effective treatment for depression, developed in 1950s
- Phenelzine (Nardil), selegiline (Emsam) are examples
- Not a first-line treatment due to significant risk with drug-food or drug-drug interactions.
- Foods containing tyramine (e.g. aged foods, wine, cheese) cause hypertensive crisis; also interacts with a variety of other drugs, including Demerol and pseudoephedrine
Describe tricyclic antidepressants
Tricyclic antidepressants
- Imipramine (Tofranil), amitriptyline (Elavil) are examples
- Side effects include dry mouth, constipation, weight gain, orthostatic hypotension, and sexual dysfunction
- Usual daily dose 25-300 mg, depending on specific drug
- Rarely used now for depression; too lethal in event of overdose (cardiac arrhythmias and seizures)
- Still used for other indications including chronic pain
