Depressive Disorders Flashcards
Depression Basic Facts
- twice as common in females than males
- depression increases risk for CAD, DM, and worsening prognosis
- 3/4 experience recurrent depression
- Risk of recurrent depression is higher if the index episode occurs at an earlier age and if there is a FH of depression
- longer depression goes untreated, the worse the prognosis
- 2/3 of completed suicides occurred in depressed pts.
Risk Factor For Depression
1) Female gender
2) +Family history of MDD
3) Stressful life events
4) Adverse childhood events:
5) Certain personality traits (neuroticism)
MDD diagnostic criteria
- Depressed mood AND/OR loss of interest/pleasure (anhedonia) accompanied by other depressive symptom.
- if pt. has BOTH depressed mood and anhedonia they only need 3 additional depressive s/s to be diagnosed
- if pt. has ONLY 1 of depressed mood or anhedonia they need 4 additional depressive s/s to be diagnosed
Additional Depressive Symptoms
- Insomnia or hypersomnia
- Significant weight loss or weight gain (eg, 5 percent within a month) or decrease or increase in appetite nearly every day
- Psychomotor retardation or agitation nearly every day that is observable by others
- Fatigue or low energy
- Decreased ability to concentrate, think, or make decisions
- Thoughts of worthlessness or excessive or inappropriate guilt
- Recurrent thoughts of death or suicidal ideation, or a suicide attempt
SIGECAPS mnemonic for diagnosing MDD
S: insomnia/hypersomnia I: reduced interest/pleasure G: excessive guilt/worthlessness E: reduced energy/fatigue C: diminished concentration/indecision A: loss of/increase appetite/weight P: psychomotor agitation/retardation S: thoughts of suicide/attempt/thinking of death
Subtypes of depression
Anxious, mixed, melancholic, atypical, psychotic, catatonic, peri-partum, seasonal
Severity of Depression is based on:
of symps and degree of impairment
Subtype of depression characterized by:
- very common, worse prognosis, slower to respond to tx
- Keyed up/tense, restless, can’t concentrate because of worry, fear something awful might happen, fear loss of control
Anxious depression
Subtype of Depression characterized by:
-s/s of mania but does not meet criteria: 3 or more present nearly every day during the episode of MDD:
-Elated mood, grandiose, talkative, FOI (flight of ideas),
-Increased energy, high risk activities, decreased need for sleep
(this is a mix between depression and bipolar disorder)
Mixed Depression
Subtype of Depression characterized by:
- 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 (vs either alone) or ECT.
Psychotic depression
Subtype of depression characterized by:
- if symptoms occurred during pregnancy or in the 4 wks following delivery
- Post partum mood episodes with psychosis(depression or Manic): 1:500-1:1000.
Peri-partum depression
Persistant Depressive d/o
Depressed mood more days than not for ≥ 2yrs, Plus ≥2 of:
~Poor appetite/overeating ~Insomnia/hypersomnia ~Low energy/fatigue ~Low self esteem ~Poor concentration or indecision ~Hopelessness *during the 2 yr period the patient has never been without the symptoms for more than 2 months.
Other Specified Depressive d/o
1) short duration depressive episodes (4-13 days)
2) depressive episode with insufficient amount of symptoms
Unspecified Depressive d/o
Depression is present, causes impairment, doesn’t meet full criteria but you don’t want to specify the reasons why and includes situation in which there is insufficient information to make a more specified diagnosis.
-Often diagnosed in ED
Substance Induced Depressive d/o
-Depressed mood or anhedonia
- There is evidence from history/PE or labs of both:
1) symptoms developed during or soon after substance intox/withdrawal
2) the involved substance/medication is capable of producing the symptoms noted.
neurobiology of depression
↓ activity in the PFC impairs its inhibitory action on the limbic structures which in turn are overactive.
- Normally the frontal lobe is what helps stop us from doing reckless things. In depression, there is an impairment in the inhibitory ability of the frontal lobe
- The limbic system is also overactive in depression
Changes noted in depression
↓ vol @ ant cingulate, orbitofrontal cortex, hippocampus, putamen & caudate
Abnormal regional blood flow & glucose metabolism in multiple Prefrontal, cortical & limbic structures
Hyperactivity @ Ventromedial PFC (causes anx/dep/rumination/tension)
Hypoactivity @ Dorsolateral PFC (psychomotor retardation/apathy/dec attention & memory)
Neurochemical/hormonal Abnormalities in Depression
Increased: ~Cortisol ~CRH `Pro inflammatory cytokines
Decreased:
~Brain Derived Neurotrophic factor
~5-HT Neurotransmission (serotonin)
~NA Neurotransmission (norepinephrine)
Monoamine Hypothesis
impaired adrenergic, serotonergic, dopaminergic activity causes depression.
HPA Deregulation theory
Comes from the fact that people with depression normally have increased levels of cortisol
Inflammation, reduced neurogenesis/neuroplasticity Theory of Depression
Comes from the BDNF, and TNF saying that inflammation of the brain is the cause of the depression
Important Aspects of Depression Assessment
-Determine the chronology of the current depressive symptoms and any prior history of depressive episodes and their course and treatment.
-Check duration and dose of any previous depressive medications
(Takes 2-3 weeks for initial change
Take 6-8 weeks for more serve change )
- Determine the impact of the depressive episode upon occupational and interpersonal functioning.
- Elicit alleviating or aggravating factors, including stressful life events and social or occupational circumstances.
- Address comorbid conditions: psych, medical, substances
- Screen for mania/hypomania/mixed
- Safety assessment
Medical Conditions Associated with Depression
- Thyroid dysfunction
- Cushings Dz: incidence can be as high as 80%
- Diabetes
- Collagen vascular disorder(lupus, rheumatoid arthritis)
- Vit Def(thiamine, folate, niacin, B12)
- Cardiac illness: common after MI
- Post stroke Depression
- Parkinson’s Dz: incidence 50%
- Huntington’s Dz: incidence 40%
- Wilson’s dz: incidence 20%
- Cancer
- Seizure d/o
- Pain d/o
Depression Treatment
- Education
- Medication (start with SSRI/SNRI then augment)
- Therapy
- Other (diet, exercise)
Natural Products for Treating Depression
-S-adenosyl methionine(SAMe)
(possible GI upset)
-Omega-3 Fatty Acids( EPA and DHA)
(EPA/DHA of 3:1)
-St. John’s Wort
(don’t mix with SSRI)
Things to pay attention to when monitoring outcomes
- Depression symptom severity (PHQ9)
- Tolerability
- Adherence to treatment
- Safety
