depression jimmie d. mcadams, d.o.. symptoms of depression depressed mood most of the day, nearly...
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Depression
Jimmie D. McAdams, D.O.
SYMPTOMS OF DEPRESSION
• DEPRESSED MOOD MOST OF THE DAY, NEARLY EVERY DAY
• MARKED DIMINISHED INTEREST OR PLEASURE IN ALMOST ALL CUSTOMARY ACTIVITIES
• WEIGHT LOSS OR GAIN
• TOO MUCH SLEEP
• TOO LITTLE SLEEP
SYMPTOMS OF DEPRESSION
• EITHER MARKEDLY SLOW OR AGITATED MOVEMENTS
• LOSS OF ENERGY
• POOR CONCENTRATION
• SUICIDAL THOUGHTS/ATTEMPTS
• HOPELESS/HELPLESS
• WORTHLESS
GERIATRIC SYMPTOMS
• COGNITIVE IMPAIRMENT
• APATHY AND SOCIAL WITHDRAWAL
• FOCUS ON PAIN AND OTHER PHYSICAL COMPLAINTS
• LITTLE OR NO SADNESS DISPLAYED OR ADMITTED
• NEW ONSET ANXIETY
RISK FACTORS
• POOR PHYSICAL HEALTH
• GENETICS
• PRIOR DEPRESSIONS
• POOR SOCIAL SUPPORT/LOSSES
• POLYPHARMACY
• AGE RELATED CHANGES IN NEUROTRANSMITER AND HORMONE METABOLISM AND FUNCTION
• PHYSICAL EXAM
• NEUROLOGIC EXAM
• LABORATORY TESTS
• EEG
• SLEEP STUDY
• DIAGNOSTIC IMAGING
Economic Burden of DepressionTotal Costs = $83.1 Billion Per Year*
Absenteeism43.6%
Inpatient Care10.7%
Outpatient Care/Partial Care
8.2%
Pharmaceutical Costs12.5%
Death FromSuicide
6.6%Decreased Productive Capacity
18.4%
*2000 dollars
Greenberg PE, et al. J Clin Psychiatry. 2003;64:1465-1475.
DEPRESSION KILLS
• DEPRESSED SMOKERS 40% LESS LIKELY TO QUIT
• LESS LIKELY TO ADHERE TO DAILY LOW DOSE ASPIRIN DOSE IN CORNARY ARTERY DISEASE PTS
• POST MYOCARDIAL INFARCTION PTS MORE LIKELY TO DROP OUT OF EXERCISE PROGRAMS
• INCREASES MORBIDITY IN MEDICAL ILLNESSES
• INCREASES MORTALITY IN POST MI PATIENTS, NURSING HOME PATIENTS, CANCER, CHF
SUICIDE
• 30,622 DEATHS 2001
• 5TH LEADING CAUSE OF DEATH AGE 5-14
• 3RD LEADING CAUSE OF DEATH AGE 15-24
• 4TH LEADING CAUSE OF DEATH AGE 25-44
• 80 PEOPLE PER DAY COMMIT SUICIDE
• 132,353 HOSPITALIZED FOLLOWING ATTEMPTS, 116,639 TREATED & RELEASED
• 2:3 HOMOCIDES:SUICIDES
SUICIDE
• 19% OF SUICIDES ARE 65+
• HIGHEST IN ELDERLY WHITE MALES
• GUNS
• LOWEST IN ELDERLY BLACK FEMALES
SUICIDE
• DO YOU FEEL LIKE A BURDEN
• FEEL YOURSELF OR OTHERS MAY BE BETTER OFF IF YOU WERE DEAD
• THOUGHT ABOUT TAKING YOUR LIFE.----- METHOD, MEANS, INTENT
• TRIED TO HURT SELF
• TAKING NEW RISKS
Clinical Stages in the Treatment of Depression
Sev
erit
y
Normal mood
Symptoms
Depression
Prog
ression to disorder
Relapse
Response
Remission
RecurrenceRelapse
50% improvement+
+
Recovery
Acute Continuation Maintenance
Kupfer DJ. J Clin Psychiatry. 1991;52(Suppl):28–34. Copyright 1991, Physicians Postgraduate Press. Adapted/Reprinted by permission.
DIFFERENTIAL
• MAJOR DEPRESSION
• DYSTHYMIA
• BIPOLAR, I &II DEPRESSED
• PSYCHOTIC DEPRESSION
• ADJUSTMENT DISORDER
• DEPRESSION D/T MEDICAL COND.
• DEPRESSION D/T SUBSTANCE
MEDICATIONS
• ANALGESICS ESP. NARCOTICS
• STEROIDS
• SEDATIVE / HYPNOTICS
• ANTINEOPLASTICS
• INTERFERON
AnxietyDisorders
24.9%(lifetime
prevalence)
Major Depressive
Disorder16.2%
(lifetimeprevalence)
Up to 60%Overlap
Anxiety-Depression Comorbidity
Brown TA, et al. J Abnorm Psychol. 2001;36:578-584.Kessler RC, et al. JAMA. 2003;289:3095-3105.Kessler RC, et al. Arch Gen Psychiatry. 1994;51:8-19.
The lifetime prevalence of depression is 60% in patients with social anxiety disorder
The lifetime prevalence of depression is 57% in patients with panic disorder
ANXIETY DISORDERS
• PANIC DISORDER
• AGOROPHOBIA
• PANIC DISORDER WITH AGOROPHOBIA
• SOCIAL ANXIETY DISORDER
• SPECIFIC PHOBIA
• OBSESSIVE COMPULSIVE DISORDER
• POST TRAUMATIC STRESS DISORDER
• GENERALIZED ANXIETY DISORDER
APA Treatment Guidelines• Acute phase (Months 1–2)
– Goal: achieve remission– Restore baseline level of symtomatology and
functioning• Continuation phase (Months 2–6+)
– Goal: prevent relapse of episode– Medication dose that achieved remission should
generally be used in this phase• Maintenance phase (Months 6+)
– Goal: prevent recurrence of new episode– Decision to employ maintenance treatment based on
clinical condition of patient (eg, number and severity of prior episodes)
American Psychiatric Association (APA) Practice Guidelines. Am J Psychiatry. 2000;157(Suppl):1–45.
TREATMENT
ALL DEPRESSION SHOULD BE TREATED
TREATMENT OPTIONS
• PSYCHOTHERAPY
• PHARMACOTHERAPY
• ELECTROCONVULSIVE THERAPY (ECT)
TREATMENT
• TCA’S• MOAI’S• SSRI’S• COMBINATION AGENTS• MOOD STABILIZERS• ATYPICAL ANTIPSYCHOTICS• AUGMENTATION
TCA’S
• ANTIDEPRESSANT EFFECT
• WELL STUDIED
• GENERICS AVAILABLE
• NO ABUSE POTENTIAL
• EFFECTIVE
• DELAYED ONSET
• ANTICHOLINERGIC SIDE EFFECTS
• POSTURAL HYPOTENSION
• WEIGHT GAIN
• INITIAL STIMULATION
• FATAL IN OVERDOSE
MOAI’S
• ANTIDEPRESSANT EFFECTS
• NO ABUSE POTENTIAL
• EFFECTIVE
• WELL STUDIED
• NO OVER STIMULATION
• DIETARY RESTRICTIONS
• DRUG INTERACTIONS
• DELAYED ONSET
• INSOMNIA
• POSTURAL HYPOTENSION
• WEIGHT GAIN
• SEXUAL SIDE EFFECTS
• DANGEROUS IN OVERDOSE
SSRI’S
• EFFECTIVE
• BENIGN SIDE EFFECT PROFILE
• SAFETY
• NO ABUSE POTENTIAL
• ONCE A DAY DOSING
• DELAYED ONSET OF ACTION
• EARLY ANXIOGENIC EFFECT
• SEXUAL SIDE EFFECTS
• DOSE TITRATIONS
• DYSCONTINUATION
COMBINATION AGENTS
• EFFEXOR (VENLAFAXINE)
• SERZONE
• WELLBUTRIN
• REMERON
• CYMBALTA
MOOD STABILIZERS
• LAMICTAL
• DEPAKOTE
• LITHIUM
ATYPICALS
• ABILIFY
• ZYPREXA
• GEODON
• RISPERDAL
• INVEGA
• SEROQUEL
AUGMENTATION
• CYTOMEL (T3)
• PSYCHOSTIMULANTS
• LITHIUM
• ATYPICALS
ELECTROCONVULSIVETHERAPY
• MOST EFFECTIVE FORM OF TRX
• TRX OF CHOICE FOR:• PSYCHOTIC DEPRESSION• SUICIDAL DEPRESSION• REFUSAL TO EAT/DRINK
• USED AFTER TRX FAILURES• MULTIPLE MEDICATION TRIALS• AUGMENTATIONS/COMBINATIONS
PSYCHOTHERAPY
• COGNITIVE-BEHAVIORAL• CHANGE BEHAVIOR AND MODES OF THINKING• ACTIVITY SCHEDULE• PLEASURE LOGS• EXAMINING DISTORTIONS
eg.OVERGENERALIZATIONS, CATASTROPHIZING, DICHOTOMOUS THINKING
• GENERATE NEW WAYS TO VIEW ONE’S LIFE• CHALLENGE WORTHLESS, HELPLESS, HOPELESS
• SUPPORTIVE