depression Flashcards
objectives of depression
- Diagnose depression related disorders using DSM-IV/5 criteria
- Recognize characteristics of depression
- Understand etiology and occurrence
- Learn about treatment options
A. Five (or more) of the following nine symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
- Insomnia or hypersomnia nearly every day.
SWAG
Used to differentiate between normal sadness and depression (have at least 1 of the following):
- Suicidality – serious thoughts (ideation) or attempts at killing oneself
- Weight Loss – >5% loss of body weight w/o medical cause
- Anhedonia – loss of pleasure/interest in previously enjoyable activities
- Guilt – feeling responsible for negative life events w/o reason
Atypical depression –
more likely to have weight gain and hypersomnia
Also leaden paralysis, carb cravings, rejection sensitivity
Pseudodementia –
cognitive symptoms in depressed elderly often misdiagnosed as “dementia”
Diurnal variation –
more depressed in AM, better in PM
–> Melancholic type depression
Psychomotor symptoms– physical complaints: body aches, headaches
Agitation vs. Retardation
Vegetative Depression
Mnemonic for MDD –> SIGECAPS
Sleep disturbance Interest/pleasure reduction Guilt, feeling of worthlessness Energy loss, fatigue Concentration/attention impairment Appetite changes Psychomotor symptoms Suicidal ideation
what is SWAG?
used to differentiate between normal sadness and depression (have at least 1 of the following):
- Suicidality
- Wight loss (5% loss of body weight w/o medical cause)
- Anhedonia
- Guilt
Psychomotor symptoms–
physical complaints: body aches, headaches
Agitation vs. Retardation
Vegetative Depression
Atypical depression –
more likely to have weight gain and hypersomnia
Also leaden paralysis, carb cravings, rejection sensitivity
Pseudodementia –
cognitive symptoms in depressed elderly often misdiagnosed as “dementia”
Diurnal variation –
more depressed in AM, better in PM
Melancholic type depression
Seasonal Affective Disorder (SAD)
- MDD usually associated with shorter days in winter
- Usually with atypical symptoms
- Treat with full-spectrum light exposure , psychotherapy, antidepressants
Masked Depression
- Depressed patients presenting with vague physical ailments but unaware/in denial of their depression
- Seem stoic
- Seek primary care for psychomotor or somatic symptoms instead
- Consider diagnosis only when no organic medical cause is identified and patient has other MDD symptoms
- More typically seen in elderly patients, obsessive-compulsive/narcisstic personalities
Possible medical causes of depressive symptoms:
Hypothyroidism Cushing’s Syndrome Anemia Brain injury, stroke Vitamin deficiency (B12, Folate, Vit D) Obstructive sleep apnea…
Biological Factors (etiology)
- Monoamine Deficiency
↓levels of Dopamine (DA), Serotonin (SR), Norepinephrine (NE) - Monoamine Receptor Excess Theory
- Loss of neurotrophic factors and degeneration?
- Genetics
Serotonin transporter gene
Psychosocial Factors (etiology)
Ability to cope with life stressors – Resilience Low self esteem, negative outlook Personality traits Addiction Learned helplessness Catastrophic loss Anger turned inward? Incapacity via hibernating? Learned helplessness and automatic thoughts? Social disconnect?
Front line agents antidepressants that have less severe side effects?
- Selective SR Reuptake Inhibitors (SSRI)
- Selective NE, SR Reuptake Inhibitors (SNRI)
- NE, DA Reuptake Inhibitors (NDRI)
Sedating Antidepressants (ex: Trazadone, mirtazapine)
- These block 5HT2 receptors, H1 receptors instead of SSRI mechanism
- Mirtazapine increase NE by blocking the alpha-2a NE receptor
Augmenting Strategies (for when antidepressants alone aren’t enough):
- Lithium
- Thyroid hormone
- Atypical antipsychotic
Electroconvulsive therapy (ECT)
- Shock Treatment
- Effective for severe depression, especially if non-responsive to meds
- Used when antidepressants cannot be used due to toxicity/side effects, or when antidepressants fail
- Also used when immediate resolution of symptoms is needed (i.e. patient is acutely suicidal or psychotic)
Faster-acting Treatments?
Antidepressants can take up to 8 wks to work
Only 1/3 of patients respond per STAR*D study
Psychotherapy takes longer…
? Faster-acting pharmaceuticals include psychostimulants, ketamine IV
But can cause addiction…not proven as yet
Occurrence of Depression
- Lifetime prevalence: Women > Men
- Women also more likely to seek help/treatment than men
- Higher risk for elderly who are widowed or chronically ill
- Co-morbidity of substance abuse, generalized anxiety
High # of receptors and/or low # of transmitter =
Depression
what are the two dysfunctional neuroanatomy in depressed state?
- hypoactive dorsolateral prefrontal cortex DLPFC
2. hyperactive amygdala
Psychological Treatments
1. Therapies include: Family Interpersonal Psychoanalytic/Psychodynamic Behavioral Cognitive 2. Some evidence claims psychological treatment + medication is more effective than either treatment modality on its own 3. New functional brain studies may suggest which patients respond to which treatment…
genetic factors in depression is only
35%, whereas 65% has to do with environmental
stress-cortisol-depression theory
stress –> increased glucocorticoids –> atrophy/death of neurons –> the brain does NOT recover
in depressed state
- cold prefrontal cortex DLPFC and
2. hot amygdala (hyperactive amygdala)
depression may be due to
Maybe it isn’t transmitters, receptors, growth factors, degeneration but neurocircuitry and connectivity
etiology of depression
- Lifetime prevalence: Women > Men
- Women also more likely to seek help/treatment than men
- Higher risk for elderly who are widowed or chronically ill
- Co-morbidity of substance abuse, generalized anxiety
Mirtazapine increase NE by
blocking the alpha-2a NE receptor
raphe nuclei
serotonin
other neurostimulation techniques
- Vagus Nerve Stimulation (VNS)
- Transcranial Magnetic Stimulation (TMS)
- Deep Brain Stimulation (DBS)
- Transcranial Direct Current Stimulation (TDCS)
N2O?
- inorganic gas
- relatively insoluble in blood
- administered as an adjuvant to volatile agents, opioid
what is the most potent volatile agent?
isoflurane
what is the least soluble and least potent of the volatile agents?
desflurane
what is the volatile agent that is less soluble, less potent, non-irritant?
sevoflurane
