Depressive Disorders Flashcards
major depression disorder accounts for ____ of lifetime psychiatric disorders:
17%
one of the big issues with depression is:
either inadequately treated (27 percent were treated adequatly within first 3 months) or not treated (34% got no treatment after being diagnosed with major depression).
why does it matter that so many patients are either not or are inadequately treated?
if the patients are not adequately treated, they will die; morbidity goes up in everything from MI recovery, breast cancer, stroke, etc
diagnosing major depressive disorder:
sigecaps
the worksheet that clinics give out to patients to help diagnose depression is called:
phq9
patient
health
quaotient 9
major depressive episode can either be:
no “oranically caused” (i.e. thyroid problem, or other medications, etc); If someone is greiving over the recent loss of a loved one, that is not necessarily a depression disorder
compare grief vs depression:
grief is less than 2 months, it fluctuates, it is preserved, minor functioning, specific guilt (or no real gult, but there is definite guilt in depression) and passive or no suicidal thoughts
TEST: “I miss my loved one and I want to commit suicide so that I can be there with them…”
depression not grief, once suicide is implicated
24 yr old comes to ed with chief complaint of “my stomach is rotting out from the inside.” States that 6 months of crying on a daily basis, decreased concentration, energy and interest in her usual hobbies. Lost 25 lbs during that time and connot get to sleep, and when she does wakes up early in the morning.
major depression: over 2 weeks of symptoms, anhedonia, crying, anergia, decreased concentration, 25 lb weight loss, and insomnia (early morning waking).
25 yr old with chief complaint of depressed mood for 1 month. Mother died 1 month ago, and since then has felt sad and been very tearful. Difficulty concentration, lost 3lbs, not sleeping soundly through the night:
uncomplicated bereavement (symptoms such as major depression, sadness, weepiness, insomnia, reduced appetitie, weight loss. Considered normal if less than 2 months. For this to be major depression, it would have to accompany marked functinal impairment, morbid preoccupations with unrealistic guilt or worthlessness, suicidal ideation, marked psychomotor retardaion, and psychotic symptoms in addition to the original symptoms described above).
45 yr old states “ever since my husband died suddenly of a hear attack 9 weeks ago, I can’t sleep.” Since then the patient has a very depressed mood, been crying, lost interest in activities, is fatigued, and has insomnia. Why is this major depression instead of bereavement?
the patient exhibits a marked functional impairment: guilt about things other than actions taken or not taken by the survivor at the time of loved one’s death, thoughts of death other than the survivor feeling he/she would be better off dead without the loved one, a morbid preoccupation with worthlessness, maked psychomotor retardation, marked and prolonged function impariment, and hallucinations other than the survivor believeing he can hear the voice of the loved one
39 yr old married woman presents with 1 month of a gradually worsening depressed mood, with increased sleep, low energy, and difficulty concentrating, but no appetite or weight changes. Her medical history is significant for multiple sclerosis, but she is currently not taking medication. Her mental status exam is notable for psychomotor slowing and a depressed and blunted affect. Physical exam demonstrates several different sensory and motor deficits.
major depressive disorder du to another medical condition
52 yr old executive presents with the new onset of depression, early-morning awakening, decreased energy, distractibility, anhedonia, poor appetite, and weight loss for the past 3 months. His symptoms began shortly after he suffered a MI, and although he experienced significant sequelae, he felst less motivated and fulfilled in his life and work, believing that he is now “vulnerable.” As a result, he does not push himself as he used to and his work output is beginning to decline. He feels “empty” but denies suicidal ideation
major depression disorder
14 yr old presents with 15 months of being irritable and depressed almost constantly. The boy has difficulty concentrating, and has lost 5 lbs during that time without trying. He states that he feels as if he has always been depressed, and he feels hopeless about ever feeling better. He denies suicidal ideation or hallucinations. He is sleeping well and doing well in school, though his teachers have noticed that he does not seem to be able to concentrate as well as he had previously.
dythymic disorder (for adults it is 2 years)
_____ presents as a kind of low grade depression
dysthymia (depression most of the day, more days than not, for 2 years)
dysthymia presents with:
appetite, sleep, self-esteem, concentration decline for up to 2 years
other dysphoric disorders in the dsm include:
premenstrual dysphoric disorder
19 yr old woman has history of anger and irritability which occurs on monthly on an average. During this time, she reports feeling anxious and “about to explode,” which notes during this time she can’t concentrate and sleeps much more than she needs to. During the several days these symptoms last, she skips her classes because she can’t function
premenstrual dysphoric disorder
premenstrual dysphoric disorder
One or more of the following during the menstrual cycle:
Marked affective lability
Marked irritability or anger
Marked depressed mood with feelings of helplessness or self-deprecating thoughts
One or more
- decreased interests, concentration, energy
- -change in appetite
- -change in sleep
- -feeling overwhelmed
- -physical changes such as bloating or breast tenderness
_____ is characterized by headaches, anxiety, depression, irritability, and emotional lability
premenstrual dysphoric disorder
severe recurrent temper oubursts manifested verbally or behaviorally 3 or more per week, mood between outbursts is irritable, present for a year, age 6-18
disruptive mood dysregulation disorder
______: A prominent and persistent disturbance in mood characterized by depressed mood or markedly diminished pleasure
There is evidence that the symptoms developed during or soon after the substance intoxication or withdrawal or after exposure to a medication
The involved medication/substance is capable of producing the symptoms.
Substance/Medication-induced Depressive Disorder: typiclly alcohol! (there is no antidepressant that can overcome drinking, so the patient needs to stop drinking and take care of the mood after they’ve stopped)
TEST: an example of depression brought on by a medical condition:
low thyroid (leads to depression)
if you have mono, you probably didn’t feel like doing anything, were fatigued, slept alot, etc, but this is more labeled as:
depression due to “medical causes”
if a loved one dies, it is ok to be sad because _______ while it is not ok to be _____ because it is a ______
sadness is an emotion, depressed, it is an illnes
to diagnose patients with depression, you only need to ask 2 questions:
Have you been feeling sad, blue or depressed?
Have you lost interest in or do you get less pleasure from the things you used to enjoy?
Sensitivity of 97%, specificity of 67% (Nimalasuriya 2009)
to avoid common clinical errors, you can’t be ok just saying “of course you’re depressed, you’ve just been diagnosed with cancer” because if they show the signs of being depressed, you have to treat it!
to avoid common clinical errors, you can’t be ok just saying “of course you’re depressed, you’ve just been diagnosed with cancer” because if they show the signs of being depressed, you have to treat it!
______ is the number 1 most common presenting symptom with organic causes
chest pain
suicide:
More common in all psychiatric diagnoses;
not just depression
Dispel myths:
talking about it probably makes it less likely to happen
Symptom as well as outcome
High risk groups (men, older, past history)
Assess prohibitions to suicide
suicide questions to ask:
When things have gotten really bad - Have you had increased thoughts about death and dying? Have you thought about hurting yourself? Have you ever acted on those thoughts? Do you have access to those means? What keeps you from doing this?
in managing a suicidal patient, you have to take note if:
the patient is not future oriented (no plans in the future), and the patient expresses a plan and means to carry out their suicide “no safety plan”
an important note about suicide is:
anxiety and depression are medical illnesses (has nothing to do with being tough, or praying to God more)
once treated, the major depression symptoms will get better over the course of ______, the continuation phase is between____ and then the maintanance phase is ____
6-12 weeks (acute), 4-9 months, 1 or more years.
patients who stop too early will have a relapse (diabetes patients get better with medication, but if they stop taking it, they get worse)
for depression treatment, you need to start them off on a medication and then ______
reevaluated every 4-6 weeks, they’ll stop early if you are not adamate about communication!
many ______ can lead someone to ______
medications, have depression
first line medication for depression
Fluoxetine (Prozac)
10mg-40mg
Mirtazapine (Remeron)
15mg-60mg
Bupropion (Wellbutrin)
150mg-450mg
Sertraline (Zoloft)
25mg-200mg
Paroxetine (Paxil)
20mg-60mg
Citalopram (Celexa)
20mg-40mg
Escitalopram (Lexapro)
10mg-40mg
Duloxetine (Cymbalta)
20mg-60 mg
Venlafaxine (Effexor)
75mg-300mg
Trazodone (Desyrel)
50mg-600mg
major obstacle of prescribing antidepresents:
need to be on them for minimun of 6-9 months
only 45% of patients stayed on for adequate duration
you need to treat towards remission-not response
55 yr old woman presents with psychiatrist with a depressed mood, decreased energy, and weight gain with a normal appetit. She never had these symptoms before and denies past psychiatric history. Her mental status examination is significant for a depressed-appearing female but is otherwise unremarkable. Physical exam is notable for diffusely enlarged thyroid gland and coarse, brittle hair:
depressive disorder due to another medical condition (hypothyroidism); obtain thyroid studies for this patient, including determinations of thyroid stimulating hormone, triiodothyronine, and thyroxine levels
TEST: Lifetime prevalence of major depressive
episode is:
5-12% for males and 10-25% for
females
34 yo suffered from major depression in the past and has at least a 10yr period of depressed mood with insomnia, fluctuating appetite, and decreased ability to concentrate. He also notes that his self-esteem is low and is experiencing no suicidal ideation, psychotic symptoms or weight loss (continues working)
persistant depressive disorder (dysthymia)
