Depression Flashcards
By 2020, the WHO believes depression will rank at this number on leading causes of disability worldwide.
2 (behind ischemic heart disease)
How many suicides occur per year in the US?
35-40K
What are some morbidities related to depression? (read)
Suicide attempts, accidents, other illnesses, lost jobs, failures to achieve, substance abuse
What are some of the societal costs of depression? (read)
Dysfunctional families, absenteeism, decreased productivity, job related injuries, adverse effect on quality control in the workplace and school settings
What is the per year cost of depression in the US?
$120 billion per year (similar to the cost of CAD or cancer)
What is the lifetime prevalence of depression?
12-18%
What is the 1-year prevalence of depression?
6-7%
What is the peak age of depression onset?
20s (but getting lower)
Sex differences in depression?
F:M 2:1
Changes to 1:1 post-menopausaly
How many times greater is your risk of depression if you have a positive family history?
2-3x
Generally, what is the root cause of depression in females?
Males?
Women: perceived deficiencies in caring relationships and interpersonal loss.
Men: perceived failing to achieve expected goals that lowers their self esteem
Are males or females more likely to express depressive sx somatically?
Females
However, if you include sx that many men experience such as anger/aggression, substance abuse, and risk taking, then incidences of depression are =
Name some life events that increase the risk of depression.
- Divorced, separated, unmarried - some risk
- Early parental losses, postpartum - higher risk
- Negative life events - highest risk
What months duration is it most common for depressive episodes to last?
8-18 months
Recall: what are the recurrence rates for depression after 1 episode? 2? 3?
1: 50%
2: 75%
3+: 95%
When are physician depression rates highest?
Internship
What are some reasons/theories for the high incidence of depression?
- Greater recognition and awareness
- Increased genetic predisposition 2/2 greater gene
pooling - Greater expression of certain genes leading to subsequent defective neuronal connections which are more vulnerable to environmental modifiers (chronic stress)
- Dietary changes: omega‐6‐fatty acids»omega‐3‐fatty acids (corn, soy»_space; fish)
Recall the Kindling theory of depression.
With each episode of depression more prone to have further depression with weaker stimuli or stressors
What is the difference between remission and recovery?
- Remission is loss of clinically diagnosable depressive sx for < 1 year in a row
- Recovery is the same for > 1 year in a row
A slip into depression during “remission” is called ___________, while a slip during “recovery” is called ___________.
- Relapse
- Recurrence
What must happen during depressive tx for there to be considered a “response”?
Any decrease in sx
What are the names of the 3 tx phases? (less important)
- Acute
- Continuation
- Maintenance (>1 year?)
During depression, recovery begins for 40% of people within _________ (time) of the onset of symptoms.
80% of individuals with their FIRST episode will recovery by ____________ (time) if they receive adequate care.
3 months
1 year
What are some features associated with lower recovery from depression?
- Psychotic features
- Prominent anxiety
- Personality disorders
- Symptom severity
What % of ppl w/depression will get help from any professional?
50%
35% will see an M.D.; only 15% ever see a Psychiatrist
What are some reasons physicians might fail to treat or refer for depression? (read)
Time pressures, close ended interviews, inadequate disease knowledge, discomfort discussing depression
What are some medical system barriers to appropriate depression dx and tx? (read)
- Infrequent visits
- Total physician reliance
- Lack of close follow up
- Lack of time to educate and advocate
- Lack of monitoring of adherence and outcomes
- Lack of time to support behavioral changes (exercise, problem solving, etc)
What are the different categories of depressive sx?
• Vegetative Symptoms (Classic DSM 5)
• Cognitive Symptoms
• Impulse Control Problems: agitated, irritable (especially in men)
• Behavioral: family and friends
• Physical (Somatic): many people, especially
the elderly
Differentiate psychologizers, initial somaticizers, facultative somaticizers, and persistent somaticizers.
- Psychologizers: all psychologic sx
- Initial somaticizers: think they only have somatic sx but then realize they may be due to psychologic factors.
- Facultative somaticizers: realize their somatic sx are due to psychologic causes after some swaying.
- Persistent somaticizer: they continue to believe their sx are due to physiological problems only
(all relatively equally common)
What is a good question to ask initial somaticizers?
What is causing your somatic symptoms?
What is a good question to ask facultative somaticizers?
Could nerves or worries be contributing to your symptoms?
What are some reasons ppl relapse at 1 year?
- Noncompliance (similar rates to any dz–50% by 6 months)
- New significant life stressor
- Loss of medication efficacy
- Absence of psychotherapy
- Feeling better – 55%
- Adverse Reaction – 23%
- Fear of Drug Dependence – 10%
- Lack of Efficacy – 10%
- Feeling uncomfortable taking meds – 10%
- 76% of pts told their MD about noncompliance –correlated with strength of Dr.‐pt relationship
- 59% of MD’s had ego‐defensive reaction (blaming authoritarian: 10% avoided issue; 31% searched for reason
What % of pts withhold the truth from their psychiatrist?
70%
What are some reasons a pt might withhold the truth from their physician?
- I found it difficult to talk to my Dr.
- I thought my Dr. would not take it seriously if I told him
- I found it embarrassing to tell the truth
In depression, is recovery the rule, the exception, or in-b/w?
The rule
Is depression a medical illness, a character defect, or both?
Medical illness
What is the goal of depression tx?
Complete symptom remission!
Describe the indicated tx’s for mild, mod, and severe depression.
- Mild/moderate depression responds equally well
to medicine or therapy - Severe depression – both medication and therapy are essential, either alone is less valuable. More intensive levels of care might also be indicated, i.e. hospitalization.
What are the differences in severity amongst mild, mod, and severe depression?
- Mild(296.21) meets minimum criteria for MDD and although symptom intensity is distressing, they are manageable; only minor impairment in social or occupational functioning
- Moderate(296.22) – in‐between minimum and severe
- Severe(296.23) –most if not all of the MDD criteria, intensity is seriously distressing and unmanageable, social and occupational functioning are very impaired
What was the first broad-use effective tx for depression?
TCAs (1950s), although ECT present since 1930s
TCAs are effective what % of the time in treating depression?
60-70%
Name some TCAs
Imipramine Amitriptyline Desipramine Nortriptyline Clomipramine Doxepin
TCAs: MoA?
Block reuptake of 5-HT and NE at reuptake pump.
TCAs: adverse effects?
- H1 blockade: Excessive sedation, fatigue, weight gain
- M1 blockade: Confusion and memory dysfunction, excessive sedation, fatigue
- a1 noradrenergic blockade: Orthostatic hypotension, excessive sedation
- Fast Na+ channel blockade: Cardiotoxicity, cardiac conduction defects, arrhythmia
- Seizures
3 C’s (tri-Cyclics): cardiac, coma, convulsions
You can OD on TCAs in as little as this many day’s worth of medication:
10 days
Name some MAO-I’s.
Phenelzine
Tranylcypromine
Isocarboxazid
Selegiline
MAO-I’s: MoA?
Phenelzine, tranylcypromine, isocarboxazid
- vs. -
Selegiline
Inhibit MAO-A irreversibly, decreasing intracellular breakdown of DA, NE, 5-HT, and tyramine.
Selegiline: Irreversibly inhibits MAO-B, increasing DA and tyramine at low doses (inhibits MAO-A at high doses)
MAO-I’s: adverse effects?
GI: nausea, constipation Orthostasis/dizziness Sexual dysfunction Sleep disturbances: insomnia and day/night shifting Sedation Weight gain - Hypertensive crisis - Risk of serotonin syndrome (myoclonus, seizures, CV collapse, disorientation, hyperthermia, psychosis, coma...)
What tyramine-containing foods should be avoided with MAO-Is to avoid a hypertensive crisis?
- Fermented goods, aged cheeses, cured meets, liqueurs.
- Also w/drugs that increase adrenergic stimulation, NE reuptake blockers
Which MAO-i is available transdermally?
Selegiline
Indications for SSRIs?
bulimia or anorexia?
- Depression
- GAD
- Panic d/o
- PTSD
- OCD
- Impulse control d/o’s
- Bulimia (not anorexia)
- Social anxiety d/o
- Cardiac d/o ppx
SSRIs: adverse effects?
- Which is more prone to causing anxiety during 1st week of use?
A/w too much 5-HT agonism:
GI: low appetite, N/D, constipation, dry mouth
Anxiety during 1st week use (esp. paroxetine)
CNS: insomnia, sedation, HA, dizziness
Sex dysfunction: loss of libido, impotence, anorgasmia
Emotional numbing
Akithisia/involuntary movements
Which SSRI and which SNRI are most a/w discontinuation syndrome?
SSRI: paroxetine
SNRI: venlafaxine
Do SSRIs pose a greater risk of miscarriage?
Probably not
Which SSRI is most a/w congenital craniofacial abnormalities when taken during pragnancy?
Paroxetine
Women exposed to SSRIs 1st trimester slightly higher risk of this mental d/o in their child.
Autism
- Can also see R amygala decrease in volume (2/2 cortisol exposure)
Does SSRI get into the breast milk?
Yes, but minimal and not harmful
How does the suicide risk change in adolescence who are on SSRIs?
Risk from 2% jumps to 4% in studies but no actual
completed suicides > 4000 patients
(Results: black box warning, 25% less antidepressants since 2004 in children – recent uptick in completed suicides in adolescents)
How do adverse effects of SNRIs contrast to SSRIs?
- Same side effect profile as SSRIs but milder.
- Dose-dependent increase in BP (venlafaxine)
- Diaphoresis (via NE-reuptake inhibition)
- Discontinuation syndrome (esp. venlafaxine, desvenlafaxine–taper when discontinuing)
Mirtazepine: MoA?
- Blockade of both NE and 5-HT2/3 nerve terminals’ presynaptic alpha2 receptors (increases 5-HT, NE activity)
Mirtazepine: adverse effects?
5-HT1A agonist: antidepressant/anti-anxiety effects
5-HT2A antagonism: sleep restoration, no sexual dysfunction (which is caused by agonism there)
5-HT2C antagonism: weight gain
5-HT3 antagonism: GI side effects (combats those of SSRIs/SNRIs)
Sedating at low doses (helps w/insomnia), may be stimulating at high doses.
Buproprion: MoA?
NE and DA reuptake inhibitor. Resembles amphetamine.
Buproprion: indications?
Depression; tobacco dependence.
May be most effective antidepressant in BD
Buproprion: adverse effects?
- Dry mouth
- Nausea
- Insomnia
- Decreases seizure threshold (esp. at high doses)
No weight gain (perhaps minor weight loss), no sexual side effects, no sedation, no orthostatic hypotension.
Buproprion: contraindications?
- Those w/eating disorders (due to weight loss SE and increased seizure risk)
- Epilepsy
- Don’t use w/panic disorder
Nefazodone: MoA?
Adverse effects?
5-HT2A antagonist and 5-HT reuptake inhibitor
Nausea
Dry mouth
Increased appetite
No sexual dysfunction
Vilazodone (Viibryd®): MoA?
Adverse effects?
5-HT reuptake inhibitor and partial 5-HT1A agonist.
GI: N/V/D
Insomnia
No weight gain
No sexual dysfunction
Vortioxetine (Brintellix®): MoA?
Adverse effects?
5-HT reuptake inhibitor and partial 5-HT1A agonist (similar to vilazodone, but lower affinities at NE and DA uptake sites). Also 5-HT1B agonist, as well as 5-HT3/7 (targets of atypical antipsychotics).
GI: N > V/D/constipation
Some sexual dysfunction at higher doses
No weight gain
What is the response rate of sx in SSRIs compared to PBO?
65‐75%
- placebo as high as 45%
If patient stays in treatment for depression, there is a >__% chance of symptom REDUCTION.
> 98%
What does remission mean, generally?
• Presence of mental health: optimism, vigor, self‐confidence
• Return to one’s usual self
• General sense of well being
• Very low number or severity of symptoms if using a rating scale
(Chance of relapse much higher without remission)
What are some initial therapeutic questions you can ask with depression?
- Ask patients their theories as to why they are depressed
- Ask patients what they think it will take for them to
improve - Work off of those ideas for best compliance and
recovery
What are some indications for psychotherapy alone with depression tx?
- Patient preference
- Mild‐to‐moderate functional impairment
- Acute onset related to adverse event(s)
- First depressive episode
- Availability of competent therapists
Describe the approach of Cognitive Therapy.
– Wide applicability
– Here and Now
– Very little exploration of the person
– Correction of abnormal thought connections due to one’s experience
– Catastrophic thinking, black and white thinking, overvaluation, etc.
– Homework, repetition
Describe the approach of Interpersonal Therapy.
– Narrower applicability
– Here and Now
– Use the Relationship, with you as a vehicle
– Grief, role transition, role dispute, interpersonal deficits the main areas of focus
– Patterns of past poor interactions
– Redefine one’s relationship with others
Describe the approach of Behavioral Therapy.
– Learning models, healthy eating
– Relaxation models, exercise
– Specific techniques and general techniques
– Very effective for anxiety disorders and many types of “stress”
– Common for all of us to use some of this ‐ very few
masters
Describe the approach of Solution-Based Therapy.
– Positive psychology
– Determine what should change for the patient to feel better
– Look at what strategies and skills the pt already has from the past that might prove helpful again
– Based on the pt’s strengths, come up with new or better ways to manage
– Try to change external situations to the betterment of the pt’s condition
What are some complementary techniques/strategies to include w/therapy (not meds).
- omega 3 fatty acids
- Exercise
- Mindfulness based therapies
Describe the approach of Mindfulness-Based Therapy.
– Present centered thought awareness: each thought, feeling, sensation acknowledged and accepted
– Self regulation; adopting curiosity
– Optimizes PFC regulation of the amygdala and balances right and left activity of the prefrontal areas (left-reward; right‐avoidance)
Describe the approach of Insight-Oriented Treatment.
– Very powerful but long process of therapy and training
– Based on Freud and childhood developmental traumas
– Very hard to determine outcome
– Personality change part of the therapy
– Expensive and not for everyone
– Predominant Rx from 1920’s ‐ 1970’s
Which therapeutic technique is most often used?
Supportive (Ego Binding)
- E.g., what are the pluses and minuses of doing this vs that
What are some specifiers to MDD and other depressive dx’s?
- With anxious distress (note overlap w/ GAD)
- With mixed features (some hypomanic symptoms)
- With psychotic features
- With melancholic features
- With catatonia
- With peripartum onset
- With seasonal mood pattern
- With atypical features
What is “melancholic depression”?
A. During worst of the depression either loss of all
pleasure or lack of reactivity to usually pleasant things
B. 3 or more of the following:
– Distinct quality of depressed mood
– Worse in the AM
– Early awakening (2 hrs before normal)
– Psychomotor agitation/retardation
– Weight loss (vs. weight gain in “atypical depression”)
– Guilt
(Classic depressive syndrome, thought to be
predominantly biological based due to the severity and
symptom presentation)
In which demo can depression be more likely to p/w:
somatic, irritable sx
Elderly
In which demo can depression be more likely to p/w: behavioral changes, changes in friends, grades, use of drugs
Adolescents
In which cx can depression be more likely to p/w stoicism?
Azns
In which cx can depression be more likely to p/w exagerated sx?
Hispanics
In which cx can depression be more likely to p/w minimized sx?
African-Americans
In what % of cases of depression can another co-morbidity be found?
60%
- 25% of the time there are 3 or more Psychiatric disorders identified
- More comorbidites = worse prognosis
What are some d/o’s that are commonly comorbid w/MDD?
– Substance Abuse – Anxiety Disorders (Panic, GAD, Social Anxiety) – Somatoform Disorders – OCD – Eating Disorders – Personality Disorders – Trauma
In Recurrent Major Depression, the need for
_______________ therapy has been well documented.
maintenance
What is the DOC for pediatric depression?
Fluoxetine (Prozac)
*What is the triad of sx seen in serotonin syndrome?
- AMS
- Autonomic dysregulation
- Neurmuscular hyperactivity (e.g. myoclonus)
- Most SSRIs should be d/c’d __ weeks prior to beginning an MAO-i to avoid serotonin syndrome.
- What SSRI requires longer?
2 weeks
Fluoxetine (Prozac)
- 5 weeks (longer T1/2)
What are the features of “atypical depression”?
- Mood reactivity (i.e., mood brightens in response to actual or potential positive events)
- 2+ of the following:
- Weight gain
- ^ sleeping (as opposed to the insomnia in melancholic depression)
- Leaden paralysis
- Interpersonal rejection sensitivity –> social or occupational impairment
