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