Depression Flashcards
Significant issues with adolescents and mental health
- context for looking at it
- developmental framework
- significance for FNP practice
- concerns about how to address them
Statistics with adolescents and mental health
- four million children/adolescents in US have serious mental disorder that causes significant functional impairment
Of children 9-17 years old, 21% have
a diagnosable mental or addictive disorder
half of all lifetime mental disorders begin by what age
14
Why does depression stand out in adolescents
- affects growth and development
- affects school performance
- affects family life/relationships
- affects adolescent adjustment
- potential to affect long-term functioning
Depression in adolescents is difficult to diagnosis why
because it can be difficult to distinguish it from normal adolescent growth and development
Depression in adolescents is the leading cause of what
suicidal behavior and suicide
Major depression in adolescence is a psychosocial dysfunction manifested by
- severe sadness
- withdrawn behavior
- boredom
- low self-esteem
- feeling helpless and hopeless
- sense that there is no meaning to life
Depression in adolescence must be differentiated between
symptoms of depression from chronic, sad, irritable moods, which are normal experiences;
Must decide which behaviors are normal variants, developmental transitions, temperamental manifestations, or primary manifestations of psychiatric disorders
DSM-5 classifications for depression diagnosis
- major depressive disorder
- persistent depressive disorder {dysthymia}
- premenstrual dysphoric disorder {PMDD}
- substance-/medication-induced depressive disorder
- depressive disorder d/t another medical condition
Major Depressive Disorder {MDD} DSM-5 criteria
5 or more symptoms must be present during same 2-week period; with at least one of the symptoms being depressed mood or loss of interest or pleasure:
- depressed or irritable mood
- diminished interest or pleasure in activities
- weight change or appetite disturbance
- insomnia or hypersomnia
Persistent Depressive Disorder {dysthymia} DSM-5 criteria
- an overwhelming, chronic state of depression
- depressed mood most days for at least 2 years with baseline irritable or depressed
- has not gone for more than 2 months without 2+ of the following sx:
a. poor appetite or overeating
b. insomnia or hypersomnia
c. low energy
d. low self-esteem
e. difficulty making decisions
f. feelings of hopelessness - symptoms must cause significant distress in social, work, school, or other areas of functioning
With persistent depressive disorder {dysthymia} you must rule out
- substance abuse
- manic episodes
- other medical conditions
What underlies the risk for depression
genetics:
children with depressed parents have 3 x the risk to be diagnosed, with peak incidence between 15-20 years old
What is common with adolescent depression
it is often chronic and comes and goes
what are the reasons for not treating depression in child/adolescence
- stigma attached to mental illness
- atypical presentations
- lack of adequate mental health education
- lack of providers
- insurance issues
What is a big problem for younger children with depression
underdiagnosis and treatment d/t tendency to somatize, to present with general aches and pains
Traditional Depression Signs
- sadness
- tearfulness
- depressed mood
- sleep disturbance
- appetite disturbance
- poor concentration
- suicidal ideation or actions
Incidence of depression
- women>men
Consider depression with
- unusual and recurring fatigue
- unexplained weight loss
- vague, unexplained physical symptoms or “just not right” feeling
- irritability and/or apathy
- frequent dr visits
Depression overlaps with
- fibromyalgia
- migraines/headache syndrome
- premenstrual syndrome (severe)
- irritable bowel syndrome
- chronic fatigue syndrome
Brain scan for patient with depression
- is markedly different than not depressed
- decreased brain activity
- less areas of cognitive function lit up on MRI
Types of depression
- major depressive episode
- dysthymic disorder
- double depression
- seasonal affective disorder
- depression secondary to substance abuse
- postpartum depression
Major depressive episode
- single or recurrent
- is most common form
- maintains mood/function until depression hits
Dysthymic diorder
- not a major depression
- living at subpar level
double depression
- either dysthymic or major depression with anxiety
Symptoms of double depression
depression sx: - fatigue - feeling down - lack of interest anxiety sx: - insomnia - racing thoughts - inability to sit still
tretament for double depression
treatment with antidepressants will often relieve both sets of symptoms
Seasonal affective disorder
depressed in fall and winter with less exposure to ambient light
Depression secondary to substance abuse
- “chicken or the egg” situation: difficult to determine which brought on the other;
- attack on both angles
postpartum depression
- occurs directly after childbirth
- can be severe, every woman should be screened
Things to remember about depression
- depression is depression regardless of cause
- all depression merits treatment
- never make assumptions or minimize patients complaints
The overlap of anxiety and depression
- very anxious people may have underlying depression
- depression may be present in classic anxiety
- recovery may be delayed until recognized
Common comorbidities to depression
- panic attacks
- bulimia, anorexia
- obsessive-compulsive problems
- frequent mood springs
Who is at higher risk of depression
- if one + blood relatives with depression
- personal/family hx of depression
- parent loss;
- early life abuse or trauma
When are women at higher risk of depression
during hormonal shifts:
- puberty
- pregnancy
- postpartum
- menopause
* *women without previous history may present with first episode during this period
Treatment for depression during hormonal shifts
treat both hormonal fluctuations and depression
Alcohol and depression
- alcohol depresses CNS and slows down nerve firing and may make brain less active
What is a common co-occurence with depression
Alcohol abuse
Moderate drinking and depression
no more than 1 drink/day does not predispose a person to depression
Primary Care Services for depression
- do no normal PE and lab testing;
- depression that interferes with functioning is often chronic, relapsing, biological illness
Medical illnesses that mimic depression
- hypothyroidism
- low blood sugar
- vitamin D deficiency
- caffeine withdrawal
- early dementia
Educating patients about recurrence
- symptoms may recur and they don’t have to face alone
- describe as a medical illness that can recur
Fastest and most effective treatment for depression
- use of psychotherapy and medication
- some pt will say no to one or the other, or both;
- give whatever they will accept
Facts about antidepressants
- not addictive
- must be taken daily to build up
- may take 10-14 days to begin to work
- friends/family notice change before pt often
- augmenting/stopping not advisable;
- if one med doesn’t work another may
Black box warnings for antidepressants
- warn of possible increase in suicide ideation and action in adolescents
- 1% increase in suicidal ideation in adolescents
- medications more beneficial than harmful
- medications cause minimal changes in pt’s lifestyle;
Pure depression treatment
any antidepressant will yield 60-70% positive response
Antidepressants should be taken for how long
- for a minimum of 4-6 months from time pt feels well;
- if taken away too soon can precipitate relapse
- everyone should be tried off meds within first 12 months
Transitioning off of antidepressants
- collaborate with pt as to when discontinuation should happen
- counsel fearful pts to at least try
- remind pt that if depression recurs, we will know what meds work
Natural remedy preferences for depression
- St. Johns wort offered as a substitute to synthetic meds with dose 900-1800 mg/day for 1 month
- St. Johns wort affects serotonin levels
- not FDA approved
St Johns wort for depression may lower
estrogen levels;
- women taking OBC or hormone replacement and may need adjustments to meds
- may need to encourage a backup BC method until efficacy is determined
St. Johns wort should not be combied with
antidepressants
adherence to antidepressant treatment
- pt may have difficulty accepting diagnosis and need for medication.
- 77% stop meds before completing full course;
- 50% stop within first 30days
what should be explored if patient is resistant to antidepressants
talk therapy
5 points of patient education for depression
- take med as prescribed every day;
- It may take time to see a response
- do not stop taking medication without contacting PCP
- do not stop med just because you feel better
- Call PCP with any concerns or questions
Adjunctive recommendations for depression
- exercise generally helps but not specific to depression
- diet changes to maintain nutrition
- sleep hygiene and daily structure (get up even if you have nothing to do)
Long term management of depression
- recognize that once stabilized, continuation of psychotherapy and/or meds are independent decisions
- work with pt to determine action plan
- do not stop both psychotherapy and meds at same time
Electroconvulsive therapy for depression
- modality not done in primary care
- most effective treatment available, statistically
- not used most often (very invasive)
- neurotransmitters can change, many side effects to inducing seizures in patients
- widely misunderstood and unnecissarily avoided
- used for severe and intractable depression
- unilateral treatments minimize side effects
Amount of Electroconvulsive therapy for depression
6-12 treatments over 4-6 weeks
Biomarkers for depression
- three of nine particular blood levels are elevated when someone becomes depressed;
- potential for screening test for at-risk patients
inflammatory markers for depression
- elevated with depression;
- unsure of intersection between inflammation and depression
