Depression and Anxiety

Depression and AnxietyHope and Amy

Depression learning outcomesDefine the main symptoms aetiology and neurological basis for depressionDescribe the pharmacological and interventional approaches used in the treatment of depressionDescribe the classes and mechanisms of action of the most common antidepressantsDescribe the problem and side-effects associated with antidepressant drugs

Mood and affectDefine mood:A patients sustained, subjectively experienced emotional state over a period of time. Define affect:The outward manifestation of the internal emotions.Assessment and diagnosis of depressionKey to diagnosing depression is the history. In the past month have youFelt down, depressed or hopeless?Found that you no longer enjoy, or find little pleasure in life?Been feeling overly tired?ALWAYS ASSESS SUICIDE RISK

List symptoms of depressionSymptomsFor a diagnosis of depression, according to DSM-IV, 5 of the 9 following symptoms must be continuously present for the minimum of two week period:

Persistent sadness or low mood.Marked loss of interest/pleasure - anhedoniaDisturbed sleep increased or decreasedFatigue or loss of energyAgitation/slowing of movements/retardation.Poor concentration.Feelings of worthlessness/excessive guilt.Suicidal thoughts or acts red flag.Weight of appetite loss

Dead swampDEAD SWAMP depression history taking made easy!D DepressionsE Energy levelsA AnhedoniaD Death thoughts about death and self harm.

S Sleep patternW Worthlessness, guiltA AppetiteM Mental function (concentration/cognition)P psychomotor agitation and retardationMain symptoms, aetiology and neurological basis of depressionTypes of depression:Mild - Few symptoms in excess of the 5 required to make the diagnosis. Symptoms only results in minor functional impairment.Moderate Symptoms between mild and severe.Severe Most symptoms, and they markedly interfere with functioning. Can occur with or without psychotic symptoms. PatternsUnipolar dysthymia (neurotic/chronic depression less severe but longer lasting symptoms), melancholia, atypical depressionBipolar bipolar disorder, cyclothymia (cycling moods)

AetiologyTheories:MonoamineNeurohormonesImmuneCircadianPsychological factorsMonoamine theorySuggests that depression is due to a shortage of noradrenaline, serotonin and possibly dopamine.NA: locus coeruleus5HT: raphe nuclei in medulla.DA: substantia nigra and ventral tegmental area.Suggests why antidepressants are effective: as each class makes more monoamine molecules available in the synaptic cleft.NeurohormonesCORTISOLSuggested that depression could be to do with dysregulation of the HPA axis.IMmuneInflammatory responses induce HPA activity and can also induce depressive behaviour.Psychological factors(Endogenous rhythm that cycles every 24 hours).Circadian rhythms can help tell acute and chronic depression apart. Changes in circadian rhythm could cause depression.

Circadian rhythmsVulnerability factors in women:Marital separationJob lossHaving three or more children at home under the age of 14Not working outside the homeLacking a confiding relationshipLoss of a mother before the age of 11

What neurological changes can be seen in depression?CircuitryDecreased activity in prefrontal cortex and hippocampus (seat of good judgement and memory).Increased activity in amygdala and hypothalamus (fear, memory and stress)NeurogenesisDecreased arborisationDecreased synapsesPharmacologyTCAsWhat are TCAs?Tricyclic antidepressantsHow do they work? (5)5HT reuptake inhibitorNA reuptake inhibitorA1 adrenoceptor antagonistH1 receptor antagonistM1 receptor antagonist side effectsTCAsGive an example of a TCAAmitriptylline Side effects.Dry mouthBlurred visionConstipationUrinary retentionTachycardiaPostural hypotensionSSRIsWhat is an SSRI? Selective serotonin reuptake inhibitor. Give 4 examples of SSRIs?ParoxetineFluoxetine (prozac)CitalopramSertraline

SSRIsHow do they work?Inhibit the reuptake of serotonin from the synaptic cleft, allowing it to exert its effect on the post-synaptic membrane for longer. List some side effects of SSRIs:NauseaSleep disordersSexual dysfunctionDrug interactions: SEROTONIN SYNDROME!

What is serotonin syndrome?Severe condition caused by too much serotonin, either due to large doses of one drug or combinations. Caused by: SSRIs/TCAsTramadolCocaine/MDMASymptoms: increased heart rate, shivering, sweating, dilated pupils, myoclonus, high fever, seizures. DEATH.

MAOisWhat are MAOIs?Monoamine oxidase inhibitorsHow do they work?Increase noradrenaline/serotonin levels by inhibiting their breakdown in the synaptic cleft.Give an example:PhenelzineGive some side effects/important drug interactions:MUST NOT be used with SSRIs or TCAs causes an autonomic overload increases levels of neurotransmitters in the cleft and also inhibits the ability to break them down.Cheese reaction: tyramine from cheese increase the release of noradrenaline and MAOIs cannot break it down.Adrenoceptor antagonistsRelease of monoamines is modulated by adrenoceptors.1 adrenoceptors - increase agonists - speed up transmission. 1 adrenoceptors increase monoamine release into the synapse. SO agonists increase this effect.2 adrenoceptors decrease antagonists - disinhibition eg Mirtazapine. Some evidence shows increased 2 adrenoceptors in depressed patients increased inhibition.2 adrenoceptors inhibit monoamine release from presynaptic neuron, therefore antagonists prevent this inhibition.

atypical antidepressantsNRIs noradrenaline reuptake inhibitors work the same as SSRIs ReboxetineSNRIs serotonin noradrenaline reuptake inhibitors Venlafaxine. 5HT partial agonists increase levels of serotonin. BuspironeLithiumHow does it work?We dont know!Either: Acts to reduce g-protein function and inhibits IP pathway signalling, or suppresses gene function, or increases neurogenesis. Useful in mania and bipolar affective disorder used as a last resort in depression.Adverse effects: narrow therapeutic window - fine line between therapeutic and toxic. List 6 non-pharmacological treatments for depression:ExerciseLight therapyAgomelatine melatonin agonist.CBTTranscranial magnetic stimulationECTIf theres time..

Anxiety learning objectivesDescribe the key features of GADUnderstand the different treatment approachesUnderstand the transactional definition of stressDescribe the transactional model of stress.StressEffects of stress:Stress not only increases risk of illness among the healthy but also impedes recovery/worsens prognosis among the ill.Describe the stages of general adaptation syndrome:Physiological response to stress.Stages:Alarm fight or flightResistance conservation response to maintain homeostasis.Exhaustion immune failure and occurrence of disease. What is GAD?Generalised anxiety disorder.What defines GAD?Excessive uncontrollable and often irrational worry more days than not for at least 6 months.List psychological and physical symptoms:PsychologicalWorry, interrupted sleep, poor concentration, increased sensitivity to noise. PhysicalSweating, dry mouth, urinary frequency, hyperventilation, palpitations.What are 4 different treatment approaches to GAD?PharmacologicalMindfulnessCBTThought diaryTransactional model of stress urgh.How a stressor is appraised by an individual.Can help stressed people by teaching them to interpret stressors differently.Stress is what you make of it!TORTOISE WITH HAT.