Depression Flashcards
Major Depressive Disorder
Experience 5 or more of the following for at least the last 2 weeks (at least one must be # 1 or #2):
• Depressed mood
• Diminished interest or pleasure (anhedonia)
• Weight loss or weight gain (or change in appetite)
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feeling worthless or excessively guilty
• Decreased concentration or indecisiveness
• Suicidal ideation
Remember: SIGECAPS • Change in Sleep • Loss of Interest • Guilt • Lack of Energy • Poor Concentration • Change in Appetite • Psychomotor retardation or agitation • Suicidal ideation
Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
Episode NOT attributable to physiological effects of a substance or another medical condition
Occurrence of major depressive episode in NOT better explained by:
• Schizoaffective disorder
• Schizophrenia
• Schizophreniform disorder
• Delusional disorder
• Other specified and unspecified schizophrenia spectrum
• Other psychotic disorders
There has never been a manic episode or a hypomanic episode
Post-Partum Depression
- Begins prior to or within 1 month of delivery
- Symptoms: hallucinations, delusions, infanticide (rare)
- Recurrence risk: 30-50%
Seasonal Depression
- Episodes in fall or winter; remit in spring
- Symptoms: low energy, hypersomnia, overeating, craving for carbohydrates, weight gain
- At risk: women, younger people, living at higher latitudes
- Treat: phototherapy
Psychotic Depression
- Symptoms: auditory hallucinations and persecutory, religious, or somatic delusions
- Often require hospitalization and treatment with med combo (antidepressant and antipsychotic) or electroconvulsive therapy
Recognize the substance/medication-induced and other medical etiologies of depression.
Medical
o Endocrine: hypothyroidism, Addison’s disease, Cushing’s
o Neurodegenerative: Parkinson’s, Alzheimer’s, multiple sclerosis, epilepsy
o Cerebrovascular: especially strokes in left frontal lobe
o Cardiovascular
o Nutritional: Vitamin B12 deficiency, folate deficiency
o Neoplastic: pancreatic cancer, tumors in frontal lobes
o Sleep disorders: sleep apnea
o Infection: HIV/AIDS, neurosyphilis
Substances o Alcohol o Opioids o Stimulant withdrawal (ex. Cocaine, amphetamines) o Sedative-hypnotics o Corticosteroids o Anti-hypertensives (ex. Beta-blocker propranolol) o Antibiotics (ex. Interferon)
Primary psychiatric
o Major depressive disorder
o Dysthymic disorder
o Bipolar disorder
Describe the biological factors thought to contribute to the development of depression
Heritable factors: 35-40%
Polygenic disorder:
• 5-HTTPR = serotonin transporter
o Short allele copy puts patient at risk for depression if have history of childhood maltreatment
o Diathesis-stress framework: inherited vulnerability (diathesis) activated only under certain conditions (stress)
• BDNF
• COMT
Neural circuitry
• Prefrontal-Amygdala circuit:
• Ventromedial prefrontal cortex down-regulates amygdala in healthy patients
• Medication and psychotherapy can increase prefrontal control over subcortical structures
Neuroplasticity
• Capacity of brain to adapt functionally and structurally to environmental stimuli
• Experience-dependent: learning and acquiring new information; adaptive behavioral choices
• Activity-dependent: “Cells that fire together wire together”
• Antidepressant drugs enhance neuroplasticity and psychotherapy sculpts new neural circuits
Monoamine systems:
• Disruptions in function of serotonin, norepinephrine and dopamine systems → depression
Stress hormones
• Hypothalamic pituitary adrenal (HPA) axis hyperactivity (associated with severe, psychotic, and/or bipolar symptoms, or history of early life adversity)
• Activation of amygdala and parts of prefrontal cortex = stimulates cortisol secretion
• Hippocampus and anterior cingulate cortex = inhibit/regulate HPA axis
• Loss of negative feedback of cortisol → depression
Describe the psychological factors thought to contribute to the development of depression
o Learned helplessness = passive and helpless behavior even in a situation where control over aversive stimulus is possible (perceived lack of control)
• A “negative cognitive style”
o History of childhood maltreatment
o Stressful life events
MDD: epidemiology
o Lifetime prevalence = 16%
o #1 worldwide cause of disability due to non-infectious medical illness
o Not adequately identified or treated
MDD: Risk factors
o Family history o Prior personal history o Female gender o Stressful life event o Lack of social supports o Loos of parent(s) at early age o Childhood abuse o Substance use disorders o Anxiety disorders o Medical conditions (ischemic heart disease = more likely to develop depression and visa versa, if have both = more likely to die)
MDD: clinical presentation
Dysphoric mood (feeling unwell, unhappy)
Anhedonia
Vegetative symptoms: • Changes in appetite and weight • Sleep changes • Loss of energy • Psychomotor agitation or retardation
Mental status exam: • Poor eye contact • Stooped posture • Decreased facial expression • Slow, monotonous, soft speech • Verbal signs of distress (anxiety)
Cognition:
• Decreased ability to think and make decisions
• Pseudodementia in older patients = severe impairment that appears to be dementia
Psychological symptoms:
• Low self-esteem
• Critical of self
• Feel excessive guilt, worthlessness, helpless, hopeless
Suicidal ideation
MDD: prognosis
One year after onset:
• 40% still meet criteria for MDE
• 20% meet partial criteria
o MDD = often a recurrent illness
o Earlier episodes more likely from stressor, later episodes may or may not be associated with a stressor
o 5-10% go on to develop bipolar disorder
• Earlier the age of onset = more likely to develop
List the elements of a thorough suicide assessment
o Has patient make a previous attempt?
o How intense is commitment to suicide?
o How stable is client’s mental status?
o How supportive is client’s environment?
o Can person identify reasons to live?
o How good is the treatment alliance?
o What is the plan for reducing the present suicide risk?
Describe the risk factors for suicide attempt and for suicide completion.
Gender
Caucasian males = 72% suicide completions
• More likely to use firearms, abusing drugs or alchohol
Caucasian females = 3x more suicide attempts than males, but only 19% completions
Ethnicity:
• African-American men = ½ rate Caucasian; Peak risk from ages 25-40
• Native Americans = 2x overall rate
• Hispanic = ½ overall rate
Marital status
• 2x risk in single men
• 4-5x higher in divorced, widowed or separated men
Age = varies by ethnicity and gender
• Caucasian men: rates rise from 10-24, plateau, then rise after 65
• Caucasian females, African Americans, Native Americans, Hispanics: rates rise in young adulthood, then fall in general
Family history
• 50% genetic contribution
Mental illness
• 95% suicides also have history of psychiatric disorder
• Most common = mood and substance use disorders
• About 50% also have comorbid personality disorder
History of suicide attempts
Medical illness
• Includes: HIV/AIDS, Huntington’s, cancer, TBI, seizures, spinal cord injury
Suicidal ideation
Mental status
• Increased risk if have anxiety, agitation, despair, hopelessness, feeling of loss of control, shame, anger
Social and environmental stressors
• Ex: recent losses, lack of social support
• Protective factors: religious beliefs, responsibility for children
Biological factors
• Link to low levels in serotonin system
List the treatments available for depression, including psychotropic medications,
neuromodulation, psychotherapy, and exercise.
Psychotherapy = cognitive behavioral therapy
Steps:
• Notice automatic thoughts and habits
• Self-validation
• Apply new skill
Requires practice (create lasting mental change) and repetition (create new neural circuits)
Antidepressants
o Therapy + meds more effective than either alone
o Includes: SSRIs, SNRIs, others (mirtazapine, bupropion)
Other helpful medications:
• Benzodiazepines: insomnia, comorbid anxiety
• Antipsychotics: psychotic depression or augment antidepressants
• Thyroid hormone: augmentation
• Lithium: augmentation
• Psychostimulants: hasten treatment response
Somatic and neuromodulatory techniques = enhance neuroplasticity
o Electroconvulsive therapy
o Deep brain stimulation = electrode placement
Other:
o Exercise
o Phototherapy
o Omega-3 fatty acids
