Depressive disorders (Weiss) Flashcards
Depressive Disorders stats
Prevalence: 15% total, 25% woman
Cost: estimate $45-55 Billion annually US
Treatment: 2/3 of people with depression do not realize they have it (Andrew,3/2012)
only 20% of those diagnosed received
appropriate treatment
depressed patients stats
Depressed patients lose on average 5-6 hours of productive work every week
Depressed patients are more than 2 times likely to take sick days
Depressed patients are 7 times more likely to be unemployed
Depressed patients have an 11 percent decrease in the probability of getting married
Patients have a 35 percent decrease in lifetime income due to depression
Rates of undetected depression among drug and alcohol users are estimated to be at least 30 percent
According to WHO, depression was the 3rd most important cause of disease burden worldwide in 2004
A Toronto study showed workers who were treated for severe depression were 7 times more likely to be high performing than those who were not
Epidemiology
Sex: Women>Men
Age: Mean age of onset 40 years old
Race: Not differ from race to race
Socioeconomic: No correlation
Rural > Urban (?)
Marital Status:
Higher if no close relationships, divorced, separated
Cause unknown
Causative factors divided into biological factors, genetic factors, and psychosocial factors
Biological Factors
Mood disorders associated with dysregulations of biogenic amines norepinephrine, serotonin, dopamine
Neuroendocrine Regulation
Adrenal Axis: Hypersecretion of cortisol
Thyroid Axis: Abnormal regulation, autoimmune disorder (10% have antithyroid antibodies)
Growth hormone: Blunted sleep induced stimulation of growth hormone release
Neuroanatomical Factors
Pathology in the limbic system, basal ganglia, hypothalamus
Genetic Factors
Data strongly suggestive of genetic component
Pattern unknown
Family studies
- 1st degree relatives 2 to 10 times more likely
Adoption studies
- Biological children reared in nonaffected adoptive family
Twin studies
- 50% in monozygotic twins
Psychosocial Factors
Stressful life events Premorbid personality factors Learned helplessness Cognitive theory Psychodynamic theory
DSM V Depressive Disorders
Major Depressive disorder, single episode
Major Depressive disorder, recurrent
Persistent Depressive disorder (dysthymia)
Disruptive mood dysregulation disorder
Substance/Medication induced depressive disorder
Premenstrual dysphoric disorder
Depressive disorder due to another medical condition
Diagnosis
DSM V specific diagnostic criteria
(Qualifiers: Severity, Psychotic Recurrent, Single, Remission)
Significant distress, functional impairment
Not due to direct physiological effects of a substance
Not better accounted for by bereavement
– Symptoms not persist > 2 months after loss
– Not suicidal, no significant functional impairment
Major Depressive Disorder
At least one of the two: Depressed Mood Anhedonia At least 2 week period At least 4 symptoms
“SIGECAPS”
Clinical Features of major depressive disorder
Depressed Mood: Subjective or observation
Marked decrease interest
Decrease/Increase Appetite, Weight change
Sleep disturbance
Psychomotor agitation/retardation
Loss of energy
Guilt, worthlessness
Poor concentration, indecisiveness
Recurrent thoughts of death, suicidal thoughts
Mental Status Exam
General Description Appearance Hygiene Level of cooperativeness Eye contact Posture Psychomotor agitation/retardation Speech Perceptual disturbances Thought Content Suicidal Thoughts Orientation Memory Concentration Attention Judgment, Insight, Reliability
Differential Diagnosis
Bipolar Disorder Dysthmia Cyclothymia Schizoaffective Disorder Schizophrenia Anxiety Disorders Personality Disorders Substance related Disorders Uncomplicated Bereavement Premenstrual dysphoric Disorder Seasonal Affective Disorder PostPartum Depression
Depression secondary to General Medical Condition
Infections Endocrine Disorders Inflammatory Disorders Neurological Disorders Vitamin Deficiencies Neoplasms
Course and Prognosis
Course: Chronic and Relapsing course Untreated: 6-13 months Treated: 8 weeks-3months 20 year period: mean number 5-6 episodes If hospitalized, 75% recur within 5 years
Prognosis:
Poor: coexisting dysthymic disorder, alcohol abuse, anxiety disorders, multiple episodes, hospitalization, men, poor support, personality disorder, late age initial onset, psychotic component
most important part of treatment
1st SAFETY
2ND SAFETY
3RD SAFETY
First Decision to make
Do you hospitalize the patient?
Voluntary vs. Involuntary
Suicide
15% of depressed people take their own lives
Risk Factors: Male Elderly Caucasian History of previous suicide attempts Co-morbid medical illness Drug/Alcohol use Co-morbid psychiatric illness Social isolation, poor social support Low job satisfaction, financial stress
Treatment….options
Hospitalization vs. Outpatient
Complete Diagnostic Evaluation
Establish Treatment Plan
Psychosocial Therapies:
- Cognitive Therapy
- Interpersonal Therapy
- Behavioral Therapy
- Psychodynamic Therapy
- Family Therapy
Pharmacotherapy
Tricyclics SSRIs SNRIs MAOIs Bupropion Mirtazapine Atypical Antipsychotics
Augmenting Strategies
- Lithium
- Thyroid
- Stimulants
- Combination
Tricyclics
Nortriptyline
Amitriptyline
Imipramine
Desipramine
SSRIs
Fluoxetine Paroxetine Sertraline Citalopram Escitalopram Fluvoxamine
MAOIs
Phenelzine
Selegiline
Tranylcypromine
Isocaroxazid
SNRIs
Venlafaxine
Duloxetine
Desvenlafaxine
Other drugs…
Bupropion
Trazodone
Mirtazapine
Partial Responders/Augmentation
Dose? Diagnosis? Medical? Substance use? Combination of Antidepressants Lithium Thyroid Stimulants Atypical Antipsychotics Buspirone
medication Side Effects/Risks
GI Sexual Withdrawal “flu” Weight gain Seizure threshold HTN Sedation/Stimulation
SSRIs and tricyclics
SSRIs will –> tricyclic overdose symptoms when compbined with tricyclics
antidepressant that causes sleepiness
mertazopam
