Depression Flashcards
Etiology of depression: neurotransmitters, genetics, and psychosocial sressors
Neurotransmitters:
Deficiencies in serotonin, norepinephrine, dopamine, GABA, and peptide neurotransmitters (somastatin, thyroid-related hormones, and brain derived neurotrophic factors)
Over activity in other neurotransmitters including substance P, and acetylcholine, and elevated serum cortisol (with lack of diurnal variation)
- *Genetics**:1.5-3x more likely if first degree relative has recurrent depression
- 27% of children with one parent who has mood disorder will have one too (50-75% if both parents)
Psychosocial stressors: alter size of neurons, neuronal function, repair capability, and production of new neurones
- elevated cortisol in depressed patients may reduce hippocampus size
When should you consider screening adults for depression?
- Personal previous history of depression or bipolar disorder
- First-degree biologic relative with history of depression or bipolar disorders
- Patients with chronic diseases
- Obesity
- Chronic pain (e.g., backache, headache)
- Impoverished home environment
- Financial strain
- Experiencing major life changes
- Pregnant or postpartum
- Socially isolated
- Multiple vague and unexplained symptoms (e.g., gastrointestinal, cardiovascular, neurological)
- Fatigue or sleep disturbance
- Substance abuse (e.g., alcohol or drugs)
- Loss of interest in sexual activity
- Elderly age
What is the USPSTF recommendation regarding screening for depression?
“screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow up” (Grade B, USPSTF 2009).
USPSTF does not recommend one screening test over another and the optimal interval for screening is unknown
Examples of screening questionaires: Zung Self-Assessment Depression Scale, Beck Depression Inventory, General Health Questionnaire (GHQ), Center for Epidemiologic Study Depression Scale (CES-D), and the Patient Health Questionaire-2 (PHQ-2).
PHQ-2 screen:
Over the past 2 weeks, have you been bothered by:
• little interest or pleasure in doing things?
• feeling down, depressed, or hopeless
A “no” response to both questions is a negative screen.
A “yes” response to either question OR if the physician is still concerned about depression, then the physician should ask more thorough assessment questions using the Patient Health Questionnaire – 9 (PHQ-9).
The Patient Health Questionnaire – 9 (PHQ-9) is a nine item questionnaire that can be completed by the patient before or during a primary care office visit. It can reliably detect and quantify the severity of depression using the DSM-IV criteria for major depressive episode.
- A PHQ-9 score of >10 had a sensitivity of 88% and specificity of 88%
DSM-IV criteria for major depressive episode
A. At least five of the following symptoms have been present during the same two-week period, nearly every day, and represent a change from previous functioning. At least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure:
1. Depressed mood (or alternatively can be irritable mood in children and adolescents)
2. Marked diminished interest or pleasure in all, or almost all, activities
3. Significant weight loss or weight gain when not dieting
4. Insomnia or hypersomnia
5. Psychomotor retardation or agitation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide
B. Symptoms are not accounted for by a mood disorder due to a general medical condition, a substance-induced mood disorder, or bereavement (normal reaction to the death of a loved one).
C. Symptoms are not better accounted for by a psychotic disorder (e.g. schizoaffective disorder).
People who are depressed cry and feel so sad
Psychomotor change
Worthlessness/guilt
Anhedonia
Depressed mood
Concentration
Appetite chance
Fatigue
Sleep chance
Suicidal ideation
SIGECAPS
* Sleep
* Interest (anhedonia)
* Guilt
* Energy
* Concentration
* Appetite
* Psychomotor
* Suicidality
Melanchotic, psychotic, and atypical features of depression
Melancholic: total anhedonia; have best response to pharmacotherapy
Psychotic: hallucinations/delusions; highest risk for suicide - should be hospitalized
Atypical: milder depression, mood reactivity; worse response to TCA’s
Depressed mood algorithm
What are the criteria for mild to moderate depression
No clear criteria - possibly defined as 2-4 of 9 DSM for 2+ weeks
Which medical disorders often are the cause of depression?
Ischemic disease, Myocardial infarction
Heart failure
Brain cancer
Pancreatic cancer
Hyperthyroidism
Hypothyroidism
Diabetes
Parathyroid dysfunction
Cushing’s disease
Inflammatory bowel disease
Irritable bowel syndrome
Hepatic encephalopathy
Cirrhosis
Stroke
Chronic headache
Dementias
Traumatic brain injury
Multiple sclerosis
Parkinson’s disease
Epilepsy
Sleep apnea
Reactive airway disease
Lupus
Rheumatoid arthritis
Chronic fatigue syndrome
Fibromyalgia
Renal failure
Electrolyte disturbances
HIV disease
Syphilis
Hepatitis
Lyme disease
Severe anemia
What is a good initial workup to rule out medical conditions that might cause depression?
Primary care physicians should consider initial lab testing such as thyroid-stimulating hormone, complete blood count, and chemistry panel
What are common causes of depression due to a substance?
alcohol, hypnotics, sedatives, opiates, marijuana, amphetamines, cocaine, and other designer drugs (e.g., ketamine, ecstasy).
- can be due to using them or their withdrawal
Prescription meds can also affect mood: blood pressure medication (e.g., reserpine, propanolol), anticholinergics, steroids, oral contraceptives, psychotropic medications, and antineoplastic drugs
DSM IV criteria for dysthymic disorder
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least two years. Note: In children and adolescents, mood can be irritable and duration must be at least one year.
B. Presence, while depressed, of two (or more) of the following:
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
C. During the two year period (one year for children and adolescents) of the disturbance, the person has never been without the symptoms in criteria A or B for more than two-months at a time.
D. No major depressive episode has been present during the first two years of the disturbance (one year for children and adolescents); i.e, the disturbance is not better accounted for by chronic major depressive disorder, or major depressive disorder in patial remission.
E. There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
F. The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia, or delusional disorder.
G. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or general medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Bereavement
Normal reaction to loss of loved one
Sadness, weight loss, decreased appetite
Resolves within 2 months
Adjustment disorder with depressed mood
Within 3 months of identifiable pscychosocial stressor
Tx: psychotherapy > pharmacologic therapy
Seasonal Affective Disorder
Major depressive episodes with a seasonal pattern
Standard therapy + light therapy
Which psychotropic meds can be used in pregnancy safely?
SSRIs: agent of choice i.e. fluoxetine (prozac) though paroxetine (paxil) has 0.2% increased risk for congenital malformations if used in first trimester
Tricyclics also do not appear to be teratogenic
Small risk of poor neonatal adaptation if serotonertic antidepressants are taken in third trimester: 2 weeks of irritability, tachypnea, thermal instability, weak cry
Mood stabilizers appear to be teratogenic: dilantin, valproic acid, carbamezepine
Postpartum depression
Within 1 month of delivery- experience major depressive episode
Normal baby blues can last up to 10 days
Special considerations of depression in the elderly
Common presentation is insomnia, anorexia, fatigue
Pseudodementia = associated with severe depression; can be mistaken for dementia
Pseudodementia: psychological distress, inability to concentrate/complete daily tasks, marked cognitive dysfunction, profound concern over their impaired cognitive function v. dementia will minimize disability
DSM IV criteria for manic episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting 1 week (or any duration if hospitalization is necessary).
B. During the period of the mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
- Inflated self-esteem or grandiosity
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
- Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The symptoms do not meet the criteria for a Mixed Episode.
D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism).
DSM Criteria for Hypomanic Episode
A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non-depressed mood.
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism).
Mixed state
Satisfy the criteria of a major depressive episode and mania at the same time
What questions can a physician ask to assess suicidal risk?
- Current thoughts of harming or killing self
- Current plans to harming or killing self
- Prior suicide attempts (critical indicator of future suicide risk)
- Family history of mood disorder, alcoholism, or suicide
- Actions or threats of violence to others
- Access to firearms
- Male
- Elderly
- Significant comorbid anxiety or psychotic symptoms and active substance abuse
- Poor social support system or living alone
- Recent loss or separation
- Hopelessness
- Preparatory acts (e.g., putting affairs in order, suicide notes, giving away personal belongings
