Depression: Dr. Kelso Flashcards
Factors in Depression Pathogenesis
Genetics Early life adversity Social factors Psychological factors Secondary depression
Reasons for Secondary Depression
General medical disorders
Medications
Substance of abuse
Define Epigenetics
Changes in expression of genes caused by early life experiences or chronic stress
How does early life adversity potentially lead to depression?
Predisposes to major depression by altering sensitivity to stress and response to negative stimuli
Social factors that could play into depression
Isolation
Poor social relationships
Criticism from family members
Depression in social networks
Psychological factors that may lead to depression
Cognitive/Behavioral: negative/distorted patterns of thinking
Personality: neuroticism
Psychodynamic: early losses, interpersonal relationships
Symptoms of Neuroticism
Anxiety Moodiness Envy Frustration Loneliness Respond poorly to stressors Interpret ordinary situations as threatening Minor frustrations as hopelessly difficult
Medical Conditions that may Lead to Depression
Sleep apnea Hypothyroidism Vitamin D deficiency DM Chronic pain Stroke HD: ischemic, HF, cardiomyopathy Parkinson's MS Epilepsy Head injury CA COPD Dementia HIV/Neurosyphilis
Medications that may Lead to Depression
Interferon Corticosteroids Benzodiazepines Opioids Varenicline (Chantix) Beta-blockers
Drugs of Abuse that may Lead to Depression
PCP (withdrawal) Amphetamines (withdrawal) Cocaine (withdrawal) Marijuana (withdrawal) Sedative-hypnotics (intoxication) Alcohol (intoxication) Opiates (intoxication) Steroids (intoxication)
Neurobiology of Depression
Altered brain structure and function
Altered Brain Structure in Depression
Increased ventricular-brain ratio
Smaller frontal lobe volumes
Smaller hippocampal volumes
Number/density/size of neurons and glial cells are abnormal
Altered Brain Function in Depression
Abnormal functioning of monoamines, GABA, glutamate
HPA axis- excess excretion of glucocorticoids may lead to suppression of neurogenesis & hippocampal atrophy
Abnormal neuronal networks
Sleep/circadian rhythms
Inflammation
Categories of Symptoms of Major Depression
Psychologica
Neurovegetative
Psychomotor/physical
Psychological Symptoms of Major Depression
Depressed mood Numbness Anhedonia: inability to experience joy Decreased interest Irritability/anxiety Guilt/worthlessness Suicidal ideation
Neurovegetative Symptoms of Major Depression
Appetite
Sleep
Energy
Concentration
Psychomotor/Physical Symptoms of Major Depression
Psychomotor: retardation, agitation
Physical: aches/pain, weakness/malaise, GI distress
Qualifying Symptoms for Major Depression
Occur in same two weeks
Most of the day, every day
Distress or impairment
R/O substances, general medical condition, bereavement
Subtypes of Depression
Anxious Atypical Catatonic Melancholic Mixed Features Peripartum Psychotic Seasonal
Subcategories of Depression
Bipolar
Secondary: medical illness, medications, drugs of abuse
Co-morbid Psychiatric Conditions with Depression
Anxiety: generalized, panic disorder, OCD, PTSD
Substance abuse
What does SIGECAPY stand for?
S: sleep I: interest G: guilt/worthlessness E: energy C: concentration A: appetite P: psychomotor disturbance S: suicidal ideation
Evaluation of Depression
Chronology of symptoms Symptoms in the same two weeks Most of the day, every day Distress or impairment Prior Hx of depressive episodes Impact on functioning Alleviating/aggravating factors Address co-morbidity Mania/hypomania Distinguish major depression from persistent depressive disorder Suicide risk General medical illness Family Hx: depression, suicide, psychosis, bipolar Social Hx: interpersonal, occupational, financial stressors \+/- complete physical & euro exam MMSE Toxicological screen Lab screen: CBC, TSH, LFT's, chem7, Ca, B12, Folate, HIV Brain imaging \+/- EEG, LP
Types of Psychotic Features
Delusions Hallucinations Disordered though 20% of patients Higher suicide risk
Suicide Risk Factors: SAD PERSONS
S: sex (male) A: age D: depression P: previous suicide attempts E: ETOH abuse R: rational thinking loss S: social supports lacking O: organized plan N: no spouse S: sickness
When to hospitalize a patient with psychosis?
Plan
Intent
Plan
Possible Safety Treatment Plan Items
Crisis Numbers
ROI for family in chart
Commitment to adhere to meds, appts., contact office with concerns
Agree to remove lethal means
Alcohol CAGE Screening
C: cut down on drinking
A: annoyed by people criticizing your drinking
G: guilty about your drinking
E: eye opener
Other Scales to Screen for Depression
Beck depression inventory
Quick inventory of depressive symptomatology
Mood disorder questionnaire
Hamilton anxiety rating scale
Mental Status Exam Observation
Affect Cognition Psychomotor activity Ruminative thought process Speech Psychosis Suicidal thoughts
Antidepressant Classes
SSRI SNRI TCA MAOI Others: mirtazapine, buproprion, trazodone Atypical Antipsychotics
Examples of SSRI’s
Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) FLuoxetine (Prozac)
Antidepressant SE
GI disturbance: nausea, diarrhea, appetite Sexual dysfunction Anxiety Insomnia or sedation Sweating Dizziness
Examples of SNRI’s
Venlafaxine (Effexor)
Duloxetine (Cymbalta)
Examples of TCAs
Amitriptyline
Clomipramine
Doxepin
Imipramine
TCA SE
Anticholinergic
Antihistamine
Orthostatic hypotension
Cardiac
TCA Overdose
Lethal
Examples of MAOI’s
Phenelzine (Nardil)
Tranylcypromine (Parnate)
What are the Drug-Druge Interactions with MAOIs
Serotonin syndrome
HTN crisis
What are the dietary restrictions for MAOIs?
Avoid tyramine containing foods
SE of Trazodone
Sedation
Orthostasis
Priapism
Piloerection
Buproprion Considerations
Avoid seizure disorders Avoid in bulimia Enhances dopamine: anxiety, psychosis, dopaminergic agents No sexual side effects Smoking cessation Co-morbid ADHD Often used with SSRIs Consider with sleepy, slowed down patients Preg. Cat. B
Mirtazapine Considerations
Sedation
Weight gain: good for chemo/elderly patients
Less sexual side effects
Good for patients with nausea
Positive Predictors of Depression Remission
Caucasian
Female
Employed
Education
Negative Predictors of Depression Remission
Longer index episodes Drug abuse Anxiety disorders Medical disorders Lower functioning
Positives of Remission in Depression
Return of normal functioning
Lower rates of relapse
Lower risk of suicide
Less ETOH & drug abuse
Acute Treatment of Mild Depression
Psychotherapy alone
Acute Treatment of Moderate-Severe Depression
Medication
+/- therapy
Acute Treatment of Bipolar Disorder
Mood stabilizer
+/- antidepressant
Acute Treatment of Psychotic Disorder
Antipsychotic
Antidepressant
Continuation Phase of Depression Treatment
4-6 months following remission
High risk for relapse
Use full therapeutic dosage
Maintenance Phase of Depression Treatment
Risk of recurrence: #/severity previous episodes, residual symptoms, co-morbid disorders
Patient preference
SE
Education on Antidepressant Medication
Minimum 2-4 weeks to be effective
Take every day
Duration: at least 4-6 months
SE: time dependent
General Principles of Depression Treatment
Titrate to target dose Monitor for SE Monitor adherence No improvement: consider switch Limited response: consider increase or augmentation SE: switch or augment
Factors in Choosing an Antidepressant
Personal history Pharmacogenetics Family history Cost Overdose/safety SE/unique benefits Drug-drug interactions Co-morbid conditions Depression subtypes
Define Pharmacogenetics
Study of the role of genetic variation on drug response
Cheap Antidepressants
Citalopram Paroxetine Fluoxetine Sertraline Burprion SR, XL Mirtazapine
More Expensive Antidepressants
Escitalopram
Bupropion XL
Venlafaxine XR
Duloxetine
TCA Overdose
Highly lethal
Lithium Overdose
Lethal
Process of Dealing with SE of Antidepressants
Wait
Lower dose, slow titration
Change dosing schedule
Augment
Process for Dealing with Sexual SE
Drug holiday
Augment
Lower dose
Wait
Which Benzodiazepines better than others for abuse potential?
Clonazepam
Lorazepam
Discontinuation of Antidepressants
Nausea Headache Irritability Vivid dreams Vertigo Slower taper +/- benzodiazepine
SSRI Drug Interactions
Fluoxetine
Paroxetine
Fluvoxamine
Least interactions: escitalopram
Depression Subtypes
Psychotic depression
Bipolar depression
Psychotic Depression
Higher remission with combination of antidepressant & antipsychotic
Bipolar Depression
30-50% risk of cycling into mania on antidepressant without a mood stabilizer
Types of Psychotherapy
CBT: understand distortions in thinking; learn new coping strategy
IPT: grief, role transition/role dispute
interpersonal deficits
Augmentation Strategies
Bibliotherapy: self help books Relaxation techniques Meditation Exercise Apps/support groups/ telepsychology
