Depression

Question 1

What are risk factors for major depressive episode (MDE)?

Answer 1

Prior episodes depression, Family history

history of suicide attempts

pot partum, comorbid medical illmess, stressful life events, adverse childhood experiences

Active substance abuse

Females

Neuroticism

Question 2

What are psyhological factors/theories contributing to MDE?

Answer 2

Psychodynamic theories (anger directed inward or disturbed infant-mother bond)

Interpersonal Theory (absent or unsatisfactory social bonds, lack social support)

Cognitive Theory (negative)

Learned Helplessness (always going to fail)

Question 3

Discuss how the Dexamethasone Suppression Test works in a “normal” patient

Answer 3

Normally, giving Dexamethasone in a patient who is not having either Cushing’s Syndrome or Depression causes negative feedback onto glucocorticoid receptors in the Pituitary gland and decreases the release of ACTH and Cortisol and so patients have lower cortisol in response to Dexamethasone

Question 4

How is the DST used in depressed patients? What other patients?

Answer 4

Depressed patients tend to have Hypercortisolemia that is not suppressed with Dexamethasone and these patients actually demonstrate higher post-dexamethasone cortisol levels (non-suppression)

Non-suppression is seen in severe, psychotic unipolar depression, major depression with suicide attempts, pts with family history of affective disorder, bipolar disorder and mania

Question 5

What does DST non-suppression mean clinically?

Answer 5

NOT diagnostic since other psychiatric disorders are associated with it but correlates with higher rates of relapse

DST returns to normal within 1-3 weeks before clinical remission and reverst to non-suppression within 103 weeks of clinical relapse

Question 6

How is the HPT axis involved in depression?

Answer 6

Thyroid disorders are found in 5-10% of people with depression

TSH is routine part of admission in labs

Thyroid hormones can be used as anti-depressant augmentation

Question 7

What sleep patterns are seen in people with MDE?

Answer 7

Abnormal sleep is one of the most common symptoms

Changes include: delayed sleep onset, decreased sleep continuity (more waking), decreased REM latency, Longer first REM, abnormal Delta sleep (slow wave sleep)

Question 8

Discuss MDD Epidemiology - men vs women, prevalence, other populations more at risk?

Answer 8

7% prevalence in US, prominent in 20 yos for first ddx

Women 1.5-3x higher prevalence than men

Higher in divorced patients than in married (especially men)

higher in Medically Ill patients

Question 9

How do men and women experience MDD differently typically?

Answer 9

Women experience more sadness, worthlessness and excessive guilt

Men experience fatigue, irritability, anhedonia, and insomnia

Question 10

What is the main part of the DSM5 criteria for MDD?

Answer 10

5 or more of the following symptoms most of the day, almost everyday, during the same 2 week period:

**At least one is either depressed mood or loss of interest/pleasure **

+

depressed mood, weight loss, insomnnia/hypersomnia, psychomotor retardation or agitation, fatigue, worthlessness/guilt, hard time thinking/concentrating

Suicide

NOT DUE to substance or other disorders and never had episodes of mania or hypomania

Question 11

What is SIG-E-CAPS?

Answer 11

Suicide

Interest

Guilt

Energy

Concentration

Appetite

Psychomotor agitation/retardation

sleep

Question 12

Compare and contrast grief vs a MDE?

Answer 12

Bereavement now recognized as a severe stressor that can precipitate the onset of MDE ; but with grieving dont see as much suicide or loss if interest (ex. woman loses her husband but still lights up when grandchildren come over)

Grief is more emptiness, decreases in intesnsity with time or comes in waves, people can still laugh, preoccupied with memories of deseased, self-esteem preserved, focus on “joining” the deceased

vs

MDE is persistent depressed mood, pervasive unhappiness and misery, self-critical and pessimistic, worthlessness and self-loathing, focused on ending ones own life bc undeserving or unable to cope with pain of depression

Question 13

What qualifies as remission? what’s the bad part?

Answer 13

2 months without qualifying symptoms or with only 1-2 symptoms present to a mild degree

*Longer symptoms present then the harder that they are to treat so good to treat early on!!!

50% experience recurrence of MDE and each new episode increases risk for future recurrence and gets more severe

Question 14

What are indicators for a greater chance of recurrence of MDE?

Answer 14

severe symptoms in recent episode

inadequate treatment

young age

persistence of mild symptom

high expressed emotion in the family

multiple prior episodes

marital problems

Psychotic problems, anxiety, co-morbid personality disorder

Question 15

What are good prognostic indicators in MDD?

Answer 15

mild symptoms

no psychosis

advanced age at onset

no co-morbid psychiatric disorders

good social functioning for 5 years before symptoms onset

history of solid support system

Question 16

What should you be carefull of when treating MDD?

Answer 16

Many people take anti-depressants and they are bipolar but have not had manic episode yet and it flips them into mania!!!!

Especially likely if depressive episode was diagnosed in adolescents, psychotic features are present, or if theires a family history

Question 17

what is the prevalence of suicide in MDD? What are the differences in men and women?

Answer 17

80% of people who commit suicide have a mood disorder and lifetime risk of suicide in al lmood disorders in 10-20%

Women attempt is more frequently than men but men are more likely to succeed bc they use more violent methods

Question 18

Discuss factors of demographics, symptoms, thinking, and history that suggest an increased risk of suicide?

Answer 18

Demograpihcs: male, recent loss, single, widowed, divorced, older age, caucasian

Symptoms: severe depression, anxiety, hopelessness, psychosis with command hallucinations

Suicidal Thinking: specific plan, means to carry it out, absence of protective factors, rehearsal, lethality of method

History: prior attempts, family history, substance abuse, psychiatric hospitalizatoins

Question 19

What are protective factors against suicide?

Answer 19

involvment of children or pets - Fluffy needs you!!!

support and family

religion

optimism about future

Patient safet contracts

PRevious response to treatment

Question 20

What is Persistent Depressive disorder? What is the relevant DSM5 Criteria?

Answer 20

PDD = Dysthymia

*depressed mood for most of the day for at least 2 years and presence while depressed of 2 or more of the following: *

poor appetite/overeating, insomnia/hypersomnia, low energy, low self esteem, poor concentration or trouble making decisisons, hopelessness

and During the 2 year peroid the personhas never been without symptoms for more than 2 months at a time

NOT SUICIDAL - auctomatically qualifies for MDD

never manic, mixed episodes, other psychotic disorders, not from substances, causes significant distress

Question 21

What is the prognosis in general for dysthymia/persistent depressive disorder? What factors predict wrse outcomes?

Answer 21

20% go on to get BPAD 1 or 2

poor long-term outcome if have higher levels neuroticism, greater severity symptoms, poorer global functioning, presence of anxiety / conduct disorder

Question 22

What is the timing like for Premenstrual Dysphoric DisordeR? what can help symptoms? What ar eRisk factors?

Answer 22

symotoms that start after menarche and can worsen as menopause approaches

OCPs can help Premenstryal Dysphoric Disorder

Risk FActors: high stress, interpersonal trauma, seasonal mood changes, heritability

Question 23

What is the relevant DSM5 Criteria for Premenstrual Dysphoric Disorder?

Answer 23

the Majority of menstrual cycles have to have at least 5 symptoms in the final week before onset of menses and start to improve within a few days after onest of menses and **become minimal/absent a week post-menses **

One or more of the following: Affective Lability, Irritability/anger, depressed mood/hopelessness/self-deprecating thoughts, anxiety/tension

+

One or more of the following to reach a total of 5: decreased interest, inability to concentrate, lethargy, change in appetite, hypersomnia/insomnia, overwhlelming, physical symptoms like breast tenderness, muscle/joint pain, bloating/wegith gaine

MOST MENSTRUAL CYCLES IN 1 YEAR

Question 24

What are “other depressive Disorders”?

Answer 24

Non-Primary Depressive disorders can be due to another medical condition or substance/medication induced

Ex. IFN treatment for Hep C

Question 25

What are the broad categories of treatment for depressive disorders?

Answer 25

MEdications (SSRIs, SNRIS, TCA, MAOIs)

Psychotherapy (psychodynamic, cognitive, interpersonal)

Meds + Psychotherapy

ECT, TMS or procedures

Question 26

What are the different forms of psychotherapy and which two are particularly useful for major depression?

Answer 26

Interpersonal and Cognitive Therapy main for major depression

others include psychodynamic, behavioral, EMDR, and solution-focused

Question 27

What is the oldest and most reliable modern somatic therapy for mood disorders? How does it work? Side Effects?

Answer 27

Brain stimulation with Electroconvulsive Therapy - for pts refractory to antidepressants

Electrical stimulus applied to brain either through R (non-dominant) Unilateral electrodes or bilaterally and produce a seizure that lasts 20-150 seconds

Risk of Cognitive impairments/memory-loss most common side effect

Anterograde amensia common within 45 minutes

but them omst of the time cognitie function returns and is even better bc depression lifted

Question 28

What are other methods of brain stimulation and how do they work? Side Effects with each?

Answer 28

Vagus Nerve Stimulation - for patients refractory to 4 or more antidepressants and implant a pace-maker like device that generates pulse into vagus nerve to increase NT output and boost pt response to existing antidepressant medications (takes several weeks onset)

Side Effects: Procedural complications, hoarseness

Transcranial Magnetic Stimulation (TMS) - for pts who have failed at least 1 antidepressent they get currents of magnetic fields on Dorsolateral Prefrontal cortex for 5 days / week for 4-6 weeks

Not great remission rates

Side Effect: HA