Depressive Disorders Flashcards
Depressive disorders (8)
- Disruptive Mood Dysregulation Disorder
- MDD
- Persistent Depressive Disorder
- Premenstrual Dysmorphic
- Substance/Med induced
- Depressive due to another condition
- Other specified
- Unspecified
Risk factors of depression
Female
Family history of MDD
Stressful life events (loss of job, marital discord, major health problems, loss of relationship)
Adverse childhood events (abuse, poor parental relationships, divorce, substance abuse in home)
Certain personality traits (neuroticism - tendency to develop emotional upset)
Definition of MDD
DSM 5
Depressed mood (irritable in children) and/or loss of interest/pleasure accompanied by AT LEAST 4 other depressive symptoms lasting 2+ weeks
Depressive symptoms
SIG-E-CAPS
S: Sleep - insomnia/hypersonic
I: interest - reduced interest/pleasure
G: guilt - excessive guilt/worthlessness
E: energy - reduced energy/fatigue
C: concentration - diminished concentration/indecision
A: appetite - loss of/increase appetite/weight
P: psychomotor agitation
S: suicide - thoughts of suicide/attempt/thinking of death
Severity of MDD categorized by
Mild/Moderate/Severe
of symptoms and degree of impairment
Subtypes of MDD
Anxious, mixed, melancholic, atypical, psychotic, catatonic, peri-partum, seasonal
Anxious depression
Very common, worse prognosis (slower to respond)
Keyed up/tense, restless, can’t concentrate, thinking something awful might happen, fear of losing control
Mixed depression
S/s of mania but doesn’t meet criteria (3 or more present nearly every day during episode)
Elated mood, grandiose, talkative, FOI, increased energy, high risk activities, decreased need for sleep
Psychotic depression
Symptoms of depression with delusions and/or hallucinations
Content of psychosis typically mood congruent (consistent with depressive themes of guilt, deserving punishment) but can be mood-incongruent
Particularly responsive to antidepressant PLUS antipsychotic or ECT
Peri-partum depression
Symptoms occur during pregnancy or in 4 weeks following delivery
Post part Ulm mood episodes with psychosis (depression or manic)
Risk factors = prior postpartum episode, hx of depression, hx of bipolar, +FH of bipolar
Also screen for delusions/hallucinations of harm to child
Persistent depressive D/o
Less symptoms, but constant
Depressed mood more days than not for AT LEAST 2 years PLUS 2 of:
-poor appetite/overeating, insomnia/hypersomnia, low energy/fatigue, low self esteem, poor concentration, hopelessness
Patient must have never been without symptoms for more than 2 months
Other specified depressive D/o
Short duration depressive episodes (4-13 days)
OR
Depressive episodes with insufficient symptoms
Unspecified depressive d/o
Depression is present, causes impairment
Doesn’t meet full criteria but you don’t want to specify reasons why and includes situation where there is insufficient information to make more specified diagnosis
“I think that they have something going on” – esp. in ER
Substance/medication induced depressive disorder
Depressed mood (anhedonia)
Evidence from history/PE or labs of both symptoms developed soon after (intox/withdrawal) or involved substance/med is capable of producing the symptoms (side effects)
Neuro circuit of emotion
Limbic system and PFC
In depression: PFC is impaired and the limbic system is overactive
changes in which region of the brain are noted with depression
PFC
Amygdala
Hippocampus
Brian changes in brain
Decreased volume in anterior cinigulate, orbitofrontal cortex, hippocampus, putamen, caudate
Abnormal regional blood flow and glucose metabolism in prefrontal cortical and limbic structures
Hyperactivity @ ventromedial PFC
Hypoactivity @ dorsolateral PFC
Neurochemical abnormalities in depression
Increased
Cortisol
CRH
Pro-inflammatory cytokines (TNF, IL-1, IL-6)
Decreased neuro chemical abnormalities ini depression
Brain derived neurotrophic factor
5-HT neurotransmission (serotonin)
NA Neurotransmission (norepinephrine)
Theories of depression
Monoamine hypothesis
HPA axis deregulation
Inflammation, reduced neurogenesis/neuroplasticity
Common disorders associated with depression
Thyroid dysfunction
Diabetes
Cushings
SLE
vitamins deficiencies
Cardiac illness
Post CVA
Parkinson’s Dz
Huntington’s disease
Wilsions dx
Cancer
Impact of depression on medical co-morbidity
Depression significantly influences course of concomitant medical dz
DM1/2 with depression are at higher risk for diabetic complications
Elderly patients who are depressed have higher risk of falls
Mortality risk increases in those who have depression and then go on to have MI or cancer
Diagnostic tools for depression
Speaking to doctors involved in their care
Face to face interview
Labs
Review of prior treament methods
PHQ
VA/DoD. Guideline
Optimal treatment setting
Least restrictive environment
Consider severity, co-morbitidies , support system
Re-evaluate on an ongoing basis
Treatment for depression
Education (illness, common misconceptions, involve family)
Medication
Therapy
Other
TMAP, SSRI, augmenting strategies
Natural products
SAMe
Omega-3 Fatty Acids (EPA, DHA)
St. John’s wart
St John’s wart
About 40 clinical trials for monotherapy
Generally supports efficacy for depression but there are some mixed results
Dose: 900-1800mg/day
Generally well tolerated
Don’t mix SSRI serotonin syndrome
Omega 3s
Supported in efficacy as mono therapy and augmenting agent
EPA is more antidepressogenic than DHA
Dosing 1000 mg daily
EPA/DHA 3:1
S-Adenosyl methionine
Supported efficacy for monotherapy some have shown benefit as augmenting
Dosing: 800-1600 mg/day, empty stomach
Well tolerated, possible mild GI upset
Monitoring outcomes
What do yo pay attention to:
Depression symptom severity
Tolerability
Adherence to treatment
Safety
