MDD ch 13 Flashcards
Epi
16% in adults HIgher in women Increased risk in childbearing years. Age of onset 20 yrs, mean age 27 After age 50 then medical reason usually.
Anticipation - earlier onset and increased severity of a genetic disorder that shows change from one generation to the next.
Cutlrue - higher in cultures that emphasize individual responsonsbility for self development.
Risk: female, hypersensitivity to negative stimuli, previous anxiety and depression, fx hx of MDD, child abuse, hx suicide attempts, pp, medical illness, lack of social support, alcohol or SA, zone, low SES, low educational achievement, unemployment, stress life events.
Etiology
Etiology- evolutionalty theory genetic influence 37% kindling model dysregulation of NT model - psychosocial theories - cognitive, interpersonal, learned helplessness, attachment, developmental.
Bio - fewer prefrontal cortex neurons as well as decreased blood flow and blood sugar. Dense glial cells.
Reduced blood flow and metabolic activity in FC and BG. Increased blood flow and metabolism in amygdala, orbital cortex, and thalamus.
Serotonin - regulates neruovegetative signs of depression
NE - modulates behavior and attention and gives emotional component to memories.
DA - linked to anhedonia.
Glutamate- excitatory, involved learning, memory and synaptic plasticity.
GABA - inhibitor , quiets overactive neurons.
Cortisol - mobilizes energy and fight or flight response.
Thyroid abnormalities - regulates the BMR.
Insulin resistance.
Clinical presentation
Sleep disturbances most common symptom.
S/S in these domains - mood, circadian/vegetative, cognitive, and motor
Specifiers -
a. mild - minimum level required to make diagnosis, minor impairment
b. moderate - excess of minimum required, greater impairment
c. severe without psychotic features - several in excess of minimal requirements, symptoms interfere and are unable to function socially, or occupationally or maintain self-care.
d. severe with psychotic features - delusion or hallucinations are present and severely impairment, often danger to themselves or others and require hospitalization.
Chronic - if full criteria me MD episode met continuously for at least the past 2 years.
If psychotic features, then more likely to have -
younger at onset more severe depression more paranoia symptoms more rumination morre feelings of guilt more psychomotor agitation more feelings of worthlessness more suicidal ideation, more functional impairment
Clinical status specifiers:
in partial remission - s/s present but not fully meet criteria or if no significant s/s lasting less than 2 months following end of an episode.
full remission - no significant s/s present for 2 months.
Longittudinal specifies - inter-episode - if full remission attained between 2 most recent mood episodes.
without inter-episode - full remission is not attained between the two most recent mood episodes.
MAJOR DEPRESSIVE EPISODE SPECIFIERS -
- MDD with catatonic features - immobility, mutism, echolalia, posturing, negativism, mannerism, stereotypes.
2. Mdd with melancholic features - loss of pleasure in all activities, lack of response to pleasurable event, and three of the following: diurnal variation, early morning awakening, slowed motor activity or agitation loss of appetite, wt loss, expressions of inappropriate guilt
- MDD with atypical features - characterized by mood reactivity, i.e. mood improves when something good or pleasurable happens. Characterized by:
unusually excessive need for sleep
arms or legs heavy and leaden
overeating,
wt gain,
inability to anticipate pleasure, but does experience pleasure once involved in activity,
anxieyt,
rejection sensitivy
fluctuation course in respnse to events,
impairment of functioning,
changes in relationships due to perceived rejection.
Often comorbid with SA, bipolar, and axis II personality.
those with early onset of atypical depression , before age 20, have lower levels of cortisol, severe chronic course, poor response to tricyclics.
4. MDD with pp onset - Requires that onset of depression be within 4 weeks of delivery and depression be present for 2 weeks with loss of interest in daily activities and causes everyday functioning impairment. In additions, must have at least four of these symptoms: wt change, insomnia or hypersomnia, psychomotor retardation or agitation, fatigue, loss of energy, feelings of worthlessness or guilt, decreased concentration, recurrent thoughts of death.
Baby blues - occur within first 2 days of delivery et may peak on 5-7 day. Educate family.
Mdd with pp onset - 13% of new moms.
Risk factors - prior episode, hx of mood do, fx hx of mood do, hx of drug or SA. , low social support, conflicted marriages, pregnancy ambivalence, single parents, low self esteem, financial difficulties, and child care stress.
Tx options - psychotherapy, psychosocial interventions, ECT if breast-feeding.
PPpsychosis - bipolar, schizopaffective, and brief psychotic d. can cause pp psychosis.
Usually due to bipolar d/. Antidepressants exacerbate manic episodes. Requires hospitalization.
Comorbid
with medical, psychiatric, neurological disorders.
Suicide
Women make more attempts.
Men commit more often.
Risks same as risk for depression.
Short term risk - panic attacks, severe anxiety, loss of pleasure, moderate alchol abuse, depressive turmoil,inability to concentrate. Jail inmates at 4 times higher risk of suicide than prison.
Tx anxiety, severe insomnia, depression, and panic attacks to decrease risk of suicide.
Treatment and Assessment
dysphoric mood - ask if sad, discouraged or anxious, or feeling irritable or tense.
Labs - CBC, vitamins, tsh, RPR, UA, UDS, BAL, Preg test, HIV.
Acute tx - 6-8 weeks continuation Tx - 4-9 months Manintenance - 5 years Focus is remission. Risk of relapse is 50% with med discontinuation.
Goal of tx - remission which is minimal or no signs and return to normal functioning, no criteria for 2 months.
After remission then recovery - extended period of remission. absence of symptoms or minimal symptoms for more than 2 months.
Somatic internventions - pharmacotherapy - switch, augment, or combine medications if no benefit. ECt, vagus nerve stimulation, rTMS is FDA approved
Deprssion in children/adolescents
Simialer to adults
Persisitantedn depressed orirtibale mood that lasts at least2 weeks.
1/3 of children relapse in 2 years of first episode.
Etio:
genetic influcence 50%
childhood maltreatment
bereavemetn
Presentation:
children - feeding problem, lack of playfulness, accident prone, fears, blaming self, apologetic, vague psychical symptoms, aggressive behavior, clingy, worry about school, blaming.
Adolescents - depressed, selfdeprecaton, anger, restlessness, grouchiness, aggression, sulkiness, reluctance to paricipate in family activities, hypersensitvy to criticism. Uncommunicative or annoying, poor academic achievements, poor relationships, delinquent behavior.
Comorbid with ADhd , anxiety, disruptive behavior.
Suicide - 3rd common cause of death,firearms frequently used.
TX - CBT and IPT,
Fluoxetine only FDA approved in pediatric.
90% recover from 1st epiosde but 49-72% recurrence.
60-70% have high risk of developing depression as adults.
Dysthymia
Chronic unipolar depressive disorder with symptoms present most of the day, more days than not for 2 years.
s/s - mild level of s/s/ like anorexia, insomnia, decreased energy, low self esterrm, problems concentrating, and hopelessness. chronic course, disability.
MD episode may occur after the onset of dysthymia and is called double depression.
Etio -
Women, unmarried, less than 45 yrs, lower incomes, genetic inference.
Clinical prsentation:
Children- irritability, pessimism, deprssion. lose self esteem, poor social skills, school impairment, changes in appetite, sleep problem, gatifue, indecisive, hopelessness.
Criteria for this group requires irritable mood for 1 year.
comorbidiyt = anxieyt, SA d/ and axis II.
TX - IPT and CBT. Sertraline, buyproprion.
