Depression Flashcards
What are risk factors for major depressive episode (MDE)?
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
What are psyhological factors/theories contributing to MDE?
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)
Discuss how the Dexamethasone Suppression Test works in a “normal” patient
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
How is the DST used in depressed patients? What other patients?
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
What does DST non-suppression mean clinically?
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
How is the HPT axis involved in depression?
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
What sleep patterns are seen in people with MDE?
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)
Discuss MDD Epidemiology - men vs women, prevalence, other populations more at risk?
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
How do men and women experience MDD differently typically?
Women experience more sadness, worthlessness and excessive guilt
Men experience fatigue, irritability, anhedonia, and insomnia
What is the main part of the DSM5 criteria for MDD?
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
What is SIG-E-CAPS?
Suicide
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor agitation/retardation
sleep
Compare and contrast grief vs a MDE?
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
What qualifies as remission? what’s the bad part?
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
What are indicators for a greater chance of recurrence of MDE?
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
What are good prognostic indicators in MDD?
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
What should you be carefull of when treating MDD?
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
what is the prevalence of suicide in MDD? What are the differences in men and women?
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
Discuss factors of demographics, symptoms, thinking, and history that suggest an increased risk of suicide?
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
What are protective factors against suicide?
involvment of children or pets - Fluffy needs you!!!
support and family
religion
optimism about future
Patient safet contracts
PRevious response to treatment
What is Persistent Depressive disorder? What is the relevant DSM5 Criteria?
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
What is the prognosis in general for dysthymia/persistent depressive disorder? What factors predict wrse outcomes?
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
What is the timing like for Premenstrual Dysphoric DisordeR? what can help symptoms? What ar eRisk factors?
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
What is the relevant DSM5 Criteria for Premenstrual Dysphoric Disorder?
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
What are “other depressive Disorders”?
Non-Primary Depressive disorders can be due to another medical condition or substance/medication induced
Ex. IFN treatment for Hep C
What are the broad categories of treatment for depressive disorders?
MEdications (SSRIs, SNRIS, TCA, MAOIs)
Psychotherapy (psychodynamic, cognitive, interpersonal)
Meds + Psychotherapy
ECT, TMS or procedures
What are the different forms of psychotherapy and which two are particularly useful for major depression?
Interpersonal and Cognitive Therapy main for major depression
others include psychodynamic, behavioral, EMDR, and solution-focused
What is the oldest and most reliable modern somatic therapy for mood disorders? How does it work? Side Effects?
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
What are other methods of brain stimulation and how do they work? Side Effects with each?
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
