Exemplar : Depressive Disorders EXAM I Flashcards
an umbrella term for a variety of disorders that range from mild, moderate to severely disabling. ____ is known as a syndrome rather than a disease. while a disease is a specific condition characterized by a common underlying cause and consistent physical traits, a syndrome is a collection of signs and symptoms known to frequently appear together, but without a single known cause.
Depression
women are ___% more likely than men to experience depression during their lifetime.
70
typically accompanies other psychiatric disorders such as anxiety, PTSD, schizophrenia, substance use disorders, eating disorders, etc. People with anxiety disorders, personality disorders, adjustment disorders, and brief depressive reactions commonly present with depression. People with chronic medical problems are are at a higher risk of depression as well. Often depression may be the first sign of a medical condition. Comorbidity has been shown to result in a higher rate of suicide, greater severity of depression, and greater impairment in social and occupational functioning as well as including more coexisting illnesses, both medical and psychiatric.
Depressive Syndrome
____ are often under diagnosed but can be diagnosed with depression as young as 3 years old. May present with irritability rather than depressed mood. May not show typical signs of depression but rather feeling unwell, refusing to go to school, complaining of vague physical complaints, aggression and clingy.
Children
typically present with depression by sulking, being negative/grouchy, getting into trouble, feeling misunderstood, withdrawing from others, or running away from home. Major depression among ____ is often associated with substance use disorder and antisocial behavior. Early treatment with medication and cognitive behavioral therapy (CBT) in the first 12 weeks can help achieve remission. Children and ________ with MDD have a high rate of future recurrence.
Adolescents
Depression among older adults has been declining but it is highest among ______ _____, and is undiagnosed in 50% of this specific population. Often time associated with chronic illness and does increase the cost of health care.
elderly men.
Research suggests that the use of antidepressants in those __ and older can be risky. Studies indicate that antidepressants in older adults can lead to falls, strokes, seizures, and other adverse outcomes. SSRI’s have more negative outcomes than older adults taking TCA’s therefore SSRI’s are less likely to be given to older adults.
65
The overall basis theory is that there are changes in receptor neurotransmitter relationships in the following areas of the brain:
LIMBIC SYSTEM (which is associated with memory impairments)
PREFRONTAL CORTEX (associated with decreased mood and problems concentrating)
HIPPOCAMPUS (which is associated with memory impairments, feelings of worthlessness, hopelessness, and guilt)
AMYGDALA (anxiety and reduced motivation)
Theory of Depression
What are the primary neurotransmitters involved with depression ?
serotonin * norepinephrine * dopamine * GABA and acetylocholine
It is commonly accepted that genetic disposition to the illness combined with childhood ____ may lead to significant changes in the CNS.
Stress
Monozygotic twins (same genetic constitution) are 50% more likely that both twins will be affected by depression. Dizygotic twins are 20% more likely. B/c the mono twins concordance rates aren’t 100% it appears that other factors must be involved.
Twin Studies of Genetic Factors involved in Depression
risk for development in depression in children born to parents with a depressive illness is the same when these children are adopted by a non-depressive family
Adoptive Studies of Genetic Factors involved in Depression
supportive of a genetic link, concluding that mood disorders are heritable for some people. People with a first-degree family member with depression are two to four times more likely to become depressed.
Family studies of genetic factors involved in depression
two major neurotransmitters involved with depression that are believed to be involved in perceptions of pain.
serotonin (5-HT) and norepinephrine (NE)
regulator of sleep, appetite, and libido. Dysfunction in _____ can result in poor impulse control, low sex drive, decreased appetite, disturbed regulation of body temp, irritability.
Serotonin
may account for anergia (reduction in or lack of energy), anhedonia (inability to find meaning or pleasure), decreased concentration and diminished libido in depression.
norephinephrine
believed to be involved in major depressive episode. Dopamine neurons in the mesolimbic systems are thought to play a role in the reward and incentive behavior processes, emotional expression, and learning processes that are disrupted in depression.
GABA
when a patient presents with severe pain (commonly back pain, abdominal or pelvic pain) and deny feelings of sadness although they may suffer from other symptoms of depression. There can often times be an overlap of major depression and chronic pain.
Masked Depression
backaches or headaches may be due to MDD rather than chronic pain, and in some cases these conditions may present as the only sign of depression.
Chronic Painful Physical Conditions (CPPCs)
explains depression form an environmental, interpersonal, and life events perspective combined with biological vulnerability or predisposition (diathesis). Early life trauma may result in long-term hyerpactivity of the corticotropin-releasing factor (CRF) and norepinephrine systems of the CNS with a consequent neurotoxic effect on the hippocampus that leads to neuronal loss. Treated with CBT, Interpersonal therapy, behavior therapy, milieu therapy.
Stress Diathesis Model of Depression
proposed that people acquire a psychological predisposition to depression through early life experiences. These experiences contribute to negative, illogical and irrational thought processes that may remain dormant until they are activated during times of stress. Cognitively an individual has a very negative view of self, pessimistic view of the world, and a belief that negative reinforcement will continue. Treated with intrapersonal therapy, CBT, behavioral therapy, milieu therapy.
Cognitive Theory (Aaron Beck)
although anxiety is the initial response to a stressful situation, anxiety is replaced by depression if the person feels no control over the outcome of the situation. The rationale is that it’s the patient’s fault and nothing can be done to change it. treated with interpersonal social relationships.
Learned helplessness (Seligman)
- mood of sadness, despair, emptiness
- negative pessimistic thinking
- loss of ability to experience pleasure in life (anhedonia)
- low self-esteem
- apathy, low motivation, social withdrawal
- excessive emotional sensitivity
- irritability and low frustration tolerance
- insomnia and or hypersomnia
- disruption (mild to severe) in concentration or ability to make decisions
- SI
- excessive guilt
- indecisiveness
DSM-5 symptoms that are most prevalent in ALL types of depression
These people experience substantial pain and suffering, as well as psychological, social, and occupational disability. Patient presents with an episode of one of more major depressive episodes and no history of maniac or hypomaniac episodes. Many people who are diagnosed with ____ will later be diagnosed with bipolar disorder. Some cases include psychotic features of delusions or hallucinations. Mood congruence delusion can occur which is when patients tend to remember information that is consistent with their particular mood. For instance, “I am a bad person; therefore I am being punished”. It often remits within 3 months of 20% of patients, and 1 year for 80% of patients. Occurrence of future episodes tends to be longer and more severe and portends the risk for a continued cyclic occurrence.
Major Depressive Disorder
five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure.
- depressed mood most of the day, or nearly every day
- markedly diminished interest or pleasure in all, or almost all activities
- significant weight loss when not dieting or weight gain, or decrease/increase in appetite
- insomnia or hypersomnia
- psychomotor agitation (pacing, biting nails, smoke, tap fingers, etc) or psychomotor retardation (Slowed movements to complete inactivity or incontinence) every day
- fatigue or loss of energy (anergia)
- feelings of worthlessness or excessive inappropriate guilt
- diminished ability to think or concentrate
- recurrent thoughts of death
DSM-5 Diagnostic Criteria for major depressive disorder
5 or more of these symptoms in a 2-week period. One of which must be depressed mood or interest loss S - sleep changes I - interest loss G - guilt or worthlessness E - energy loss C - cognition A - appetite changes, more or less food P - psychomotor agitation S -suicidal ideation
memory trick to remember DSM-5 diagnosis criteria for major depressive disorder
commonly known as dysthymia or chronic depression. This form of depression is notably severe and is characterized by depressive symptoms that are present for at least 2 years. Because _____ is usually chronic in nature, it cannot be distinguished from the persons usual pattern of functioning. Although they experience social and occupational distress, it typically doesn’t warrant hospitalization unless the patient becomes suicidal. Simultaneous presentation of ____ and MDD is referred to as “double depression” The major differences between MDD and ____ is the level of severity, duration, and persistence
persistent depressive disorder
- daytime fatigue
- frequently but not always to function at work or in social situation to optimum level.
- chronic depressed/irritable mood
- eating too much/little
- difficulty sleeping, PDD often has a hard time getting to sleep, but when they do they excessively sleep (hypersomnia), and MDD it is more common to have early morning awakenings
- loss of energy for simple tasks
- Irritability
- pessimistic thoughts
- low self esteem
Notable Symptoms of PDD
What are some of the shared thoughts of MDD and PDD ?
- death
- self harm
- unexplained pain
- feelings of worthlessness
- helplessness
- hopelessness
- and low self esteem
A patient that appears depressed should always be evaluated for _____ or ______ ideations. white males complete SI more than 78% of all suicides.
suicide and homicide ideations
somatic changes and alteration in those activities necessary to support physical life and growth (sleeping, eating, elimination, etc)
Vegetative signs of depression
_____ should always include goals of safety. Even if patient doesn’t have an intent to self harm, you should help them name a person who they would contact if they were to begin to feel self-destructive. Ex (reports adequate sleep, weight gain, return of normal BM, etc)
Outcomes
______ depends upon the phase of depression that the person is in and the particular symptoms the person is exhibiting. _______ of care for a patient who is depressed is based on the individual’s symptoms and attempts to encompass a variety of areas in the person’s life. Safety is always the highest priority.
Planning
may be necessary when a person is acutely ill and involves changing the hospital environment to promote safety. IF a patient is highly suicidal, refusing food, becoming debilitated, and exhibiting psychotic depression, electroconvulsive therapy may be effective.
Mileu therapy
behavior activation therapy, cognitive behavorial therapy, and interpersonal therapy have proven to be effective in the treatment of depression.
Psychotherapy
combination of CBT and mindfulness-based stress reduction. Mindfulness is a from of meditation technique that has been used successfully in patients coping with medical or mental health disorders.
mindfulness-based cognitive therapy
widespread modality and it increases the number of people who can receive treatment at a decreased cost per individual. Offer the opportunities for the patient to socialize and to share common feelings and concerns as well as provide patients with opportunity to reach out and support others.
Group Therapy
how many weeks does it take to see improvements with antidepressant medication therapy?
1-3 weeks
what anti-depressant’s pose an increased risk for suicide in children and adolescents and can cause violent behavior, mania, or aggression
SSRIs
adults over __ should avoid SSRI’s because of increased risk for stroke, falls, epilepsy and death
65
_______ can lead to several different birth defects and should be avoided during pregnancy. Serotonin is essential for embryogenesis, heart development, and CNS and musculoskeletal system and so forth, and by inhibiting serotonin it can result in multiple birth defects.
SSRIs
What are the first line agents in regards to classes of anti-depressants?
- cyclic antidepressants (TCAs)
- Dual action antidepressants (SSRIs, SNRIs, and NDRIs)
- Atypical antidepressants
What is the second line agent in regards to classes of anti-depressants
Monoamine oxidase inhibitors (MAOIs)
inhibit the reuptake of norepinephrine and serotonin by the presynaptic neurons in the CNS. Therefore, the amount of time that NE and 5-HT are available to the postsynaptic receptors is increased. The increase in NE and 5-HT is believed to be responsible for mood elevations when TCAs are given.
Tricyclic Antidepressants
-sedative effects are attibruted to antihistamine and anticholinergic actions
-treats major depression
-therapeutic effect takes 10-14 days
-full effects may not be noted until 4-8 weeks
-dosage should always start low and gradually increase
-older adult practice “start low, go slow” give w/ caution
-cumulative effect may occur
-increases appetite
-excreted in the urine
-pregnancy Class D
(this medicine should be given at bedtime because of its sedative effects.)
Tricyclic Antidepressants
dry mouth, blurred vision, tachycarida, constipation, urinary retention, esophageal reflux, orthostatic hypotension (basically anticholinergic effects). Urinary retention and severe constipation warrant immediate medical attention. ____ is risky for cardiac patients and older adults. Patients should have cardiac workup before beginning therapy.
adverse effects of tricylic antidepressants
cardiac problems, recent MI, narrow angle glaucoma, history of seizures, pregnant women.an overdose can be lethal.
contraindications of tricylic antidepressants
can’t see
can’t pee
can’t spit
can’t sh*t
anticholinergic effects
selectively block the neuronal uptake of serotonin (5-HT, 5-HT 1 receptors), thereby leaving more serotonin available at the synaptic site.
- lower incidence of anticholinergic effects, less cardiotoxicity, and faster onset of action than the TCA’s
- onset 1-4 weeks
- peaks 2-8 weeks
- low cardio toxic effects
- caution with the elderly!
- less dangerous when taken in an overdose
- black box warning of potentially increasing SI or behavior
- This type of drug is used for depression but also anxiety disorders and OCD. Fluoxetine has been successful in women who suffer from late luteal phase dysphoric disorder and bulimia nervosa.
Selective Serotonin Reuptake Inhibitors
agitation anxiety sleep disturbance tremor sexual dysfunction tension HA dry mouth sweating weight change mild nausea and loose BM
adverse effects of SSRIs
serotonin syndrome, rare but life threatening event that is thought to be related to overaction of the central serotonin receptors, caused either by too high of a dose or interaction with other drugs. (symptoms: abdominal pain, diarrhea, sweating, fever, tachycardia (>140), elevated BP, altered mental status, myoclonus, increased muscle activity, irritability, hostility, and mood changes, restlessness (due to lack of O2 to the brain). )
toxic side effects of SSRIs
-cyproheptadine
-methysergide
-propranolol
utilized to treated serotonin syndrome (SES)
serotonin reuptake blockade
needs to be discontinued for a full 5 weeks before starting a different medication such as an MAOI. If the person is already on a MAOI they should wait at least 2 weeks before starting fluxoetine.
Fluxoetine
What is SSRIs used to treat?
- anxiety disorders
- obsessive/compulsive
- panic
- phobias
- PTSD
- psychomotor agitation
second line medication but have proven benefits for patient who have not responded to other medications or to ECT treatment. They have proven effective in treatment with those who have atypical depression. They can also be helpful in treating panic disorders, social phobias, generalized anxiety disorder, OCD, PTSD, and bulimia.
-prevents the breakdown of norepinephrine, serotonin, and dopamine in the brain, thereby increasing the levels of these brain amines and resulting in elevated mood.
monoamine oxidase inhibitors (MAOIs)
hypotension is most common and risky for elderly, sedation, weakeness, insomnia, changes in cardiac rhythm, muscle cramps, anorgasmia, urinary hesitance or constipation, weight gain.
adverse effects of MAOIs
people taking MAOI’s must restrict tyramine intake which includes :
avocado soy beans sauerkraut figs large amounts of bananas fermented meats pickled herring most cheeses yeast extract some beers and wines chocolate fava beans and ginseng and caffeinated beverages (avoid chinese food)
remains one of the most effective treatments for major depression with psychotic symptoms and for treatment of patients with life threatening psychiatric conditions. mostly reserved for people with treatment resistant depression, which exists when pharmacological interventions fail or when the side effects are too uncomfortable.
- remission can occur in 1-2 weeks
- useful in patients with bipolar disorder and depression
- helpful especially when patients present with delusions of guilt, somatic delusions, or delusions of infidelity
- usually course of treatment is 2-3 treatments per week to a total of 6-12 treatments
Electroconvulsive therapy
helpful in patients with treatment resistant depression. affects blood flow to certain parts of the brain and affects neurotransmitters including serotonin and norepinephrine. Treatment is expensive and not covered by most insurance companies. Not as high of a success rate as ECT. VNS involves surgically implanting a device called a pulsator into the upper left chest. The pulse generator is connnected by a wire to the left vagus nerve; when the generator is stimulated electrical impulses are trasmitted to areas of the brain that affect mood centers. When successful there is an improvement in mood.
Vagus Nerve Stimulation
applies priniciples of noninvasive electromagnetism to deliver an electrical field to cerebral cortices, but unlike ECT, the waves do not result in generalized seizure activity. Daily treatments lasting 40 minutes are done
Rapid Transcranial Magnetic Stimulation
used in treatment of Parkinson’s disease and patients with chronic pain. Now recently for patients with severe depression and OCD. Electrodes are implanted in chosen areas of the brain (considered a major surgery). Generator is placed under the skin near the clavicle and once activated impulses transmit signals that depolarize the local group of neurons near the implanted electrode.
Deep Brain Stimulation
a syndrome rather than a disorder and ranges from mild to moderate to disabling. Share similar traits such as (severe impairment, decreased psychosocial function, and increased mortality).
Depression
____ are diagnosed with depression/anxiety later on in life.
Men
The average age of first diagnosis for children/adolescents is ______. and is 3.5 times higher in age 18-29 years with a very high re-occurrence rate.
14.5 years old
A type of theory of depression that suggests that there are changes in the neurotransmitter relationships with the _____ which is associated with memory impairment (emotion and behavior)
limbic system
A type of theory of depression that suggests that there are changes in the neurotransmitter relationships with the _______ which is associated with decreased mood and problems concentrating.
frontal lobe
a type of theory of depression that suggests that there are changes in the neurotransmitter relationships with the _______ which is attributed to memory impairment, feelings of worthlessness, hopelessness and guilt.
hippocampus
a type of theory of depression that suggests there are changes in the neurotransmitter relationships with the ______ which is attributed to anxiety and decreased motivation.
amygdala
overactivity of 5HT receptors. Occurs when ______ are taken with or interacts with other 5HT drugs, such as MAOI. Symptoms (one should think that everything is elevated).
- restlessness
- tachycardia
- elevated BP
- delirium
- irritability
- seizures
- myoclonus
- abdominal pain (severe), diarrhea and bloating
- apnea (abnormal breathing)
- hyperpyrexia (fever)
- shock, death
Serotonin Syndrome (SES)
a medication that block different neurotransmitters and subtypes which allows them to relieve a variety of depressive symptoms. the primary use is for major depression, reactive depression, and anxiety.
Example: Buspirone, Duloxetine, Desyrel, and Buproprion
Dual Action Reuptake Inhibitors aka Atypical
