Depression Flashcards
How many people w/ depression get treatment? Adequate treatment?
50% get treatment. Just 20% get adequate treatment.
What is ratio of suicide attempts / completions?
5:1
Risk factors for suicide: #1 risk What percentage of pxs w/ bipolar attempt? Men vs women Fastest growing population Lower in which populations? Protective factors Genetic contribution Age factors
- Previous attempt is #1 risk factor
- Other psychiatric disorders increase risk. 50% of pxs w/ bipolar disorder attempt.
- Women are 3x more likely to attempt, men are 3-4x more likely to complete suicide. Men are more likely to use firearms and be abusing drugs / alcohol.
- Older adults are fastest growing population who are committing suicide.
- Suicide rates are lower in AA’s, Hispanics, and Asians, compared to whites and Native Americans.
- Marriage is protecting – Double risk in single men, 4-5x risk in divorced, widowed, or separated men compared to married men.
- Strong religious beliefs and responsibility for children are also protective.
- Family history (50% genetic contribution)
- Among those who have committed suicide, those 30 are more likely to have a mood disorder.
Aspects of proper suicide assessment
General demographics, risk factors, current mental status, prior SI, and questioning about ideation, intent, and access to means
Medical Conditions causing depression
- Endocrine disorders – Hypothyroidism, Addison’s disease, Cushing’s disease
- Neurological disorders – Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, epilepsy
- Nutritional disorders – deficiency of vitamin B12 or folate
- Neoplasia – especially pancreatic cancer and tumors in the frontal lobes
- Cerebrovascular disease – especially strokes in the left frontal lobe
- Infection – HIV/AIDS, neurosyphilis
- Sleep disorders – Sleep apnea cardiovascular disease.
Substances / meds causing depression
Alcohol, opioids, stimulants, sedatives / hypnotics, corticosteroids, antihypertensives (beta blockers), or antibiotics
What percentage of depression is genetic? Which genes?
Heritability of major depression is 35-40%.
Genes involve 5HT-TPR, BDNF, and COMT.
Diathesis-stress framework
Person may inherit vulnerability to express certain behaviors (diathesis), which are activated only under certain conditions (stress)
What is the chemical cause of anhedonia?
Loss of dopaminergic system
Risk factors for depression
Prior personal history (strongest risk factor), family history, female, stressful life events, lacking social support, childhood abuse, death / divorce of parent, substance abuse, anxiety, and medical conditions.
PHQ-2 Screen
- “In the last 2 weeks, have you felt down, depressed or hopeless?”
- “In the last 2 weeks, have you felt little interest or pleasure in doing things?”
Criteria for major depressive episode Vegetative sxs (5) Pseudodementia
- Discrete period of abnormal mood, cognitions, and behavior lasting at least 2 weeks. Core sxs are dysphoric mood and anhedonia.
- Vegetative sxs include changes in appetite, weight, sleep, loss of energy, or psychomotor agitation / retardation.
- Pseudodementia – seen in older adults who have severe depression inhibiting their ability to think or concentrate
DSM Criteria for MDD
- A – Need 5 or more of the following for at least 2 weeks (one must be #1 or 2):
- 1) depressed mood
- 2) diminished interest / pleasure (anhedonia)
- 3) weight loss / gain or change in appetite
- 4) insomnia / hypersomnia
- 5) psychomotor agitation / retardation
- 6) fatigue
- 7) feeling worthless / excessively guilty
- 8) decreased concentration / indecisiveness
- 9) suicidal ideation
- B – The sxs cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- C – The episode is not attributable to the physiological effects of a substance or other medical condition.
- D – Not better explained by other psychiatric disorder
- E – There has never been a manic or hypomanic episode.
SIGECAPS
- change in Sleep
- loss of Interest
- Guilt
- lack of Energy
- poor Concentration
- change in Appetite
- Psychomotor retardation or agitation
- Suicidal ideation
Peri / Postpartum depression
Begins w/in 1 month of delivery. Psychosis may also be involved. Different than “baby blues”, which are transient, low-level mood changes w/in 10 days of giving birth.
Who is at higher risk for seasonal depression (SAD)?
More common in women, younger pxs, and those at higher altitude
Criteria for persistent depressive disorder (AKA dysthymia)
Lasts at least 2 years. Called “double depression” when it occurs on top of MDD. At least 2 of the following sxs must be present:
• poor appetite or overeating;
• insomnia or hypersomnia;
• low energy or fatigue;
• low self-esteem;
• poor concentration or difficulty making decisions; or
• feelings of hopelessness.
Prognosis for depression
1 year after onset 40% of pxs still meet full criteria and 20% meet partial criteria.
4 main brain areas involved in depression
PFC, anterior cingulate, amygdala, and hippocampus.
Role of amygdala in depression
Important for emotional learning, emotional memory, vigilance detection, and emotion regulation
Role of hippocampus in depression
Emotional cognition
Role of insular cortex in depression
Detection of visceral states
How does PFC regulate emotion?
PFC normally down regulates activity in amygdala. This circuit is inhibited in pxs w/ depression. High amygdala activity –> HPA activation.
Which NT’s act in long-distance signaling?
5HT, NE, DA, and Ach
Where is 5HT produced?
Raphe nuclei
Where is NE produced?
Locus ceruleus
Which NT’s act in local signaling?
Glutamate and GABA
Which parts of the brain inhibit HPA activation?
Hippocampus and anterior cingulate cortex
Where does cortisol bind to cause negative feedback?
Hippocampus, PFC, hypothalamus, and pituitary. Defects in this negative feedback are seen in severe depression.
What percentage of pxs are helped by antidepressants?
60-70%
Adjunctive meds to antidepressants (5)
Benzos (to treat insomnia), antipsychotics, thyroid hormone, lithium, and psychostimulants.
Which AA is a precursor for 5HT
Which foods?
Tryptophan
Found in turkey, nuts, tofu, cheeses, fish, oats, eggs, beans, etc
Classic Triad of Serotonin Syndrome
Severe sxs
Tx
Triad: neuromuscular excitation (clonus / hyperreflexia), ANS excitation (hyperthermia / tachycardia), and altered mental state.
If severe, rhabdomyolysis (may cause kidney damage), disseminated intravascular coagulation, and adult respiratory distress syndrome may occur.
Tx w/ stopping meds, hydrating, active cooling, and sedation.
Which drugs reduce risk of suicide?
Lithium (bipolar) and clozapine (schizo)
4 Neuromodulation / Somatic Treatments for depression
- Electroconvulsive therapy – most effective treatment for severe, refractory, or psychotic depression. Safe during pregnancy. Side effects include memory loss and cardiac problems.
- Vagal nerve stimulation
- Repetitive transcranial magnetic stimulation (rTMS)
- Deep brain stimulation (requires neurosurgery)
