Major Depressive Disorder Flashcards
What moods does Depressive Disorder include?
Mild depression, moderate depression, severe depression, severe depression with psychosis
What moods does Cyclothemia include?
Elation, normal mood, dysthymia
What moods does recurrent depressive disorder include?
normal mood, dysthymia, mild depression, moderate depression, severe depression, severe depression with psychosis
What moods does Bipolar affective disorder include?
All of them
Define mood disorders
- disturbance of emotions that are severe or prolonged enough to cause impairment of functioning
- magnification of normal rxn
Define depression
period of extreme sadness and helplessness
- sadness
- feelings of worthlessness
- withdrawal from others
- changes in sleep/appetite
Define mania
period of abnormally high emotion and activity
- intense elation or irritability
- hyperactivity, talkativeness, distractibility
What is the diagnostic criteria for Major depressive disorder?
sad mood or loss of pleasure for 2 weeks, along with at least 4 other symptoms
What is the diagnostic criteria for dysthymic disorder?
Mood is down and other symptoms are present atleast 50% of the time for at least 2 years
What are the three main causes of mood disorders?
- Biological vulnerability
- psychological vulnerability
- stressful life event
What three things can a stressful life event cause?
- stress hormone effect neurotransmitters
- sense of hopelessness and negative thought process
- problems in interpersonal relationships and lack of social support
What is the most common mood disorder?
major depressive disorder
When does MDD occur?
may occur at any age but likelihood increases after puberty
MDD is prevalent in which sex most and when?
Women between time of menstruation and menopause
Define MDD
occurrence of at least a single major depressive episode, although most patients will experience recurrent episodes.
What makes women more prone to MDD than men?
- Hormones*
- girls 2x as likely to experience sexual abuse
- women have more chronic stressors
- more likely to worry about body image
- react more intensely to interpersonal loss
- women spend more time ruminating; men distract
- ruminating intensifies and prolongs sad moods
MDD risk factors
alcohol dependence comorbid chronic medical conditions female sex personal or fam hx of depression recent childbirth recent stressful evetns parental loss trauma during childhood or adulthood low parental warmth
Rate of depression is higher in which type of twin?
Identical (50%)
Fraternal is 20%
Why is the brain less active during MDD?
diminished neurotransmitter levels
Stable vs Temporary explanations
Stable: bad situation will last for a long time
Temporary: This is hard to take but I will get through this
Global vs. Specific
Global: my explanation applies to many areas of my life. ex: w/o my partner, I cant seem to do anything right.
Specific: i miss my partner but thankfully i have fam and other friends.
Internal vs External
Internal: our break up was all my fault
External: it takes 2 to make a relationship work and it wasnt meant to be
Learned helplessness
subjected to events with little or no control -> fails to succeed -> feels overwhelmed/powerless -> develop sense of helplessness -> give up and stop trying to improve the situation -> cycle repeats -> learned behavior develops
Who should be screened for MDD?
all adults that you can provide adequate resources for diagnosis, treatment and f/up.
- pregnant/postpartum women, older adults
- pts with risk factors
- pts w/ unexplained symptoms, chronic pain, anxiety, substance misuse, or nonresponse to effective treatments.
MDD 1st step for depression screening
- Over the past 2 weeks, have you felt down, depressed, or hopeless?
- Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)?
If pt answers yes to either question, this is a + screen.
MDD 2nd step for depression screening
- dig deeper and engage in conversation about mood and changes in behavior
- Have pt fill out PHQ9
Criteria for MDD on PHQ9
- checked 1 or 2 at level of ‘nearly every day’ AND 5 items from 3 to 9 checked at level of ‘for more than half’ or ‘nearly every day’
- SI (suicidal ideation) always counted if + response regardless of severity
PHQ9 score of 0-4
non-minimal depression
no treatment recommended
PHQ9 score of 5-9
mild depression
watchful waiting, reevaluate at f/up
PHQ9 score of 10-14
moderate depression
consider referral for psychotherapy and/or initiation of psychopharmacotherapy
PHQ9 score of 15-19
moderately severe depression
initiate psychopharmacotherapy and/or refer for psychotherapy
PHQ9 score of 20-27
severe depression
initiate psychopharmacotherapy
- if severe impairment or treatment resistant “expedite” referral for psychotherapy (collaborative management)
DSM V Criteria
5 or more of the following symptoms must be present during the same 2 week period & represent a change from previous functioning.
At least ONE of the symptoms must be:
- depressed mood (sad, empty hopeless)
- Anhedonia (no pleasure in normal activities)
The rest:
- significant weight loss/gain
- dec/inc in appetite
- insomnia/hypersomnia
- psychomotor agitation/retardation
- fatigue
- feeling worthless
- diminished ability to think or concentrate
- recurrent thoughts of death
- SI, suicide attempt, specific plan
SIGECAPS
sleep pattern changes interest/activity changes guilt energy changes concentration changes appetite changes psychomotor disturbances suicidal ideation
MDD specifiers
- anxious distress
- mania/hypomania
- melancholic features: anhedonia
- atypical
- mood congruent: delusions/hallucinations
- mood incongruent: delusions/hallucinations
- catatonia
- peripartum onset: during or within 4 wks of delivery
- seasonal pattern: SAD
How do you determine the severity of MDD?
- clinical interview
- PHQ-9
- assessment of severity guides treatment
- mild: may not require medication
- moderate: responds equally to medication or psychotherapy
- severe: benefits more from medication alone or combined with psychotherapy
What 4 symptoms do MDD and PDD have in common?
- depressed mood (irritable mood)
- Insomnia/hypersomnia
- Fatigue
- Poor concentration or difficulty making decisions
SSRI treatment
citalopram escitalopram fluoxetine paroxetine sertraline
Why are SSRIs our go to?
- ease of dosing and low toxicity
- good for children, adolescents and late onset depression
- less adverse effects
What are common adverse effects of SSRIs?
- GI upset
- Sexual dysfunction
- fatigue/restlessness
SNRIs
venlafaxine
desvenlafaxine
duloxetine
SNRIs are 1st line for which patients?
Those with significant fatigue and/or pain syndromes
When would you rx an SNRI?
if a patient is not responding to an SSRI
SNRI adverse effects
noradrenergic side effects: HTN
Atypical AD
bupropion
mitazapine
nefazodone & trazadone
What advantage does Bupropion have over other SSRIs?
Causes less sexual dysfunction, GI distress and it is weight neutral
Mitrazapine is associated with a high risk of _________
weight gain
If a pt came in complaining about sexual side effects/erectile dysfunction due to their SSRI/SNRI, how would you treat?
- pretreatment counseling
- sildenafil
If a pt came in complaining about undesired weight gain due to their SSRI/SNRI, how would you treat?
switch to bupropion
If a pt came in complaining about agitation due to their SSRI/SNRI, how would you treat?
switch to another SSRI/SNRI; consider mania
If a pt came in complaining about insomnia due to their SSRI/SNRI, how would you treat?
add mirtazapine, trazodone, or sedative-hypnotic
If a pt came in complaining about anxiety due to their SSRI/SNRI, how would you treat?
BENZOS during initiation of treatment
What do we have to watch out for in the elderly when rx SSRI/SNRI?
hyponatremia because it may promote osteoporosis
How long should you treat a patient with MDD?
atleast 6-9 mo with close follow up
When should you f/up with pts after they start pharmacotherapy?
1-2 weeks
If pt response to meds is inadequate, when should you modify treatment?
At 6 weeks
Possible increased suicide risk in ________, _____, _______ who start pharmacotherapy
children, adolescents and young adults
Why is there a high rate of nonadherance in the early months?
- misperception regarding how long it would take to feel better -> 2-6 weeks
- med side effects
- didn’t understand the need to continue the meds
What should you do if pt has partial response to the meds?
1st: maximize dose of initial agent
2nd: switch to another medication or add 2nd drug if needed
If the partial response continues despite switching meds or adding a drug, what should you do?
- add psychotherapy
- change AD
- augment with bupropion, mirtazapine
How long should you maintain meds for pts who experience their first episode of depression?
- treatment may take 1 to several months until remission
- continue for another 6-12 mos
How long should you maintain meds for pts who experience their multiple episodes of depression?
15 mo-3yrs
How long should you maintain meds for pts older than 70 who respond to an SSRI?
2 yrs to prevent recurrence
What to do if relapse occurs after cessation?
use AD that previously led to remission
initiate long term maintenance therapy
Life time therapy may be required for patients who have experienced greater than or equal to ___ episodes
3
Risk factors for more than one recurrence of depressive episode
fam hx of bipolar recurrence < 1 yr onset in adolescence severe depression suicided attempt
CBT
cognitive behavioral therapy
identifies and modifies dysfunctional or inaccurate thoughts and behaviors
IPT
interpersonal therapy
targets conflicts and role transitions
pt needs capacity for psychological insight
PST
problem solving therapy
practical approaches to coping with everyday problems
St Johns Worth
- treatment of mild depression only
- serious adverse effects are uncommon
- DO NOT USE WITH SSRIs: serotonin excess syndrome
- may reduce concentrations of digoxin, theophylline, simvastatin and warfarin.
- at high dose, may harm sperm cells, reduce fertility.
When to consult with behavioral health provider
diagnostic uncertainty severe symptoms heightened suicide risk need for hosp treatment resistant depression
Alternatives for Treatment resistant depression
electroconvulsive therapy
transcranial magnetic stimulation
When to consider hospitalization
SI intent to hurt others unable to care for self close observation needed detoxification or substance abuse treatment electroconvulsive therapy initiated dysfunctional family systems worse depression or interfere with treatment patients life is in jeopardy
