Depression Flashcards
What is the frequency which depression is dx and treated
Recognized half the time but then treated only half the time
Etiology of Depression
Most common pysch symptom 1 year prevelance: 5% have major depression 5.4% have dysthymic disorder in a given year see 11 million people w/ depression
How efficacious is tx for depression
80%
What are the variety of ways depression can present
• Multiple Somatic Complaints
• Anxiety
• Cultural influences
– “Nerves” “Headaches”-Latino, Mediterranean
– Weakness, Tiredness, “Imbalance”-Chinese, Asian cultures
– “Heartbroken” - Hopi
What are common somatic complaints in pts with depression
tire, blahs, headache, malaise, poor sleep, abdominal/joint aches, stressed out, GI issues, loss sexual interest
What are the more common positive predictive somatic sypmtoms for depression
sleep issues, fatigue, non specific skeletal compliant, back pain, SOB
There is a strong correlation between number of physcial symptoms and
prevalence of pyschiatric disorder: anxiety, mood or other
We see high prevalance of depression in certain medical illnesses
cancer, stroke, diabetes, Parkinsons, MI
Depressive Disorder, Dysthymic Disorder and MDD are all nesteled under
Depressive Disorders (type of mood disorder)
What are the criteria for Major Depressive Episode
Minimum 5 symptoms for at least two weeks (at least one of the follow two) – Depressed mood (irritable in kids) – Loss of interest or pleasure AND 4 of the following – Weight loss or gain – Insomnia or hypersomnia – Psychomotor retardation or agitation – Fatigue or energy loss – Worthlessness or guilt – Decreased concentration – Death thoughts; suicidal thoughts, plans, acts
What things are NOT major depressive episode when present
- B. Not Mixed Episode
- C. Clinically significant distress or impairment
- D. Not due to substance or general medical condition
- E. Not Bereavement
SIGE CAPS is way to remember MDD
*5 or more in 2 week period Sleep Interest Guilt Energy Concentration Appetite Pyschomotor Suicidality
What is the 2 question depression screen?
2-question depression screen
– Over the past 2 weeks, have you felt down or hopeless?
– Over the past 2 weeks, have you felt little interest in doing things?
A “yes” to either question is a positive screen for depression
How does the PHQ-9 work?
Patient Health Questionaire (PHQ-9)
Over the last 2 weeks, how often have you been bothered by the following problems?
Ranked 0-3 for not at all through every day
How does the scoring work for PHQ-9 screen?
5-9
10-14
5-9; minimal symptoms, support and educate to call if worse, follow up in 1 month
10-14: minor depression, dysthimia or mild major depression… antidepressant OR psychotherapy
PHQ-9 score of 15-19
Major depressive: antidepressant or psychotherapy
Score of over 20 on PHQ-9
psychotherapy and antidepressants
What are some suidice myths
- Suicide is a crazy act/rational act
- Those who talk, won’t do it; those who act don’t talk
- Broaching the subject plants the seed
- Marriage protects
- It doesn’t matter how much meds I prescribe, pts will stockpile
- If depression explainable, no need for tx
- A suicide attempt is simply a failed suicide
What questions do we ask when assessing pts risk for suicide?
• “Have things gotten to the point where you
have felt like ending it all?”
• Specific plans?
• How available is the method? • How lethal is the method?
Red flags for suicide
Red Flags: IS PATH WARM
Ideation/threatened or communicated
Substance Abuse/excessive or increased
Purposeless/no reasons for living Anxiety, Agitation/Insomnia Trapped/feeling no way out Hopelessness
Withdrawal from friends, family, society
Anger (uncontrolled)/rage/seeking revenge
Recklessness/risky acts - unthinking
Mood changes (dramatic)
What are the three stages of Grief
Shock
preoccupation with deceased
Resolution
What happens during the first stage of grief
SHOCK: • Emotions – Numbness – Sense of unreality • Somatic – Crying – Abdominal pangs/emptiness – Sighing – Tightness in throat Denial and disbelief
What occurs during the second stage of grief
• Thoughts – Dreams – Thoughts of the deceased • Motivational stage – Anhedonia – Introversion • Emotions – Guilt – Anger – Sadness • Somatic – Weakness – Anorexia – Insomnia – Fatigue
What occurs during the third stage of grief
• Thoughts
– Think of past with pleasure
• Motivational Stage
– Regain interest in activities – Form new relationships
Recommended meds for depression
- Tricyclic antidepressant (TCA)
- Selective Serotonin Reuptake Inhibitors (SSRI)
- Atypical
- Monoamine Oxidase Inhibitors (MAOI)
– Imipramine (Tofranil) – Amitriptyline (Elavil) – Desipramine (Norpramin) – Nortriptyline (Pamelor) – Doxepin (Sinequan) – Clomipramine (Anafranil
All examples of TCAs
When prescribing TCAs, what do we need to take into consideration
side effect profile: • Effective First Line Treatment • Preferred by Managed Care • Compliance Issues Due to Side Effects – Dry mouth – Sedation – Orthostatic Hypotension • Cardiac arrythmias with overdose
- Fluoxetine (Prozac)
- Sertraline (Zoloft)
- Paroxetine (Paxil)
- Citalopram (Celexa)
- Fluvoxamine (Luvox)- not approved for depression
- Escitalopram (Lexapro)
all examples of SSRIs
What do we need to keep in mind when prescribing SSRIs
DOSAGE; varies for all of them
What are side effects seen with SSRIs
Side effects – Headache, dizziness – Nausea, loose stools, constipation – Somnolence or insomnia – Sweating, tremor, dry mouth – Anxiety, restlessness – Sexual Drive
- Bupropion (Wellbutrin/Zyban) • Trazodone (Desyrel)
- Nefazodone (Serzone)
- Venlafaxine (Effexor)
- Mirtazapine (Remeron) • Duloxetine (Cymbalta) • Alprazolam (Xanax)
Atypical antipyschotics
- Phenelzine (Nardil)
- Isocarboxazid (Marplan)
- Tranylcypramine (Parnate) • Selegiline patch (Emsam)
MAOIs
What are supplemental or alternative therapies to depression
• Lithium
• Augmentation therapy – Lithium
– T-3 L-triiodothyronine Cytomel
• Psychotherapy -
• ECT (Electro-Convulsive Therapy) • Vagal Nerve Stimulation
• Transcranial Magnetic Stimulation • Deep Brain Stimulation
What are the 5 Rs of Depression tx
Response Remission Relapse REcovery Recurrence
