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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
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POOR PHYSICAL HEALTH
GENETICS
PRIOR DEPRESSIONS
POOR SOCIAL SUPPORT/LOSSES
POLYPHARMACY
AGE RELATED CHANGES IN
NEUROTRANSMITER AND HORMONE
METABOLISM AND FUNCTION
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PHYSICAL EXAM
NEUROLOGIC EXAM
LABORATORY TESTS
EEG
SLEEP STUDY
DIAGNOSTIC IMAGING
Economic Burden of Depression
Total Costs = $83.1 Billion Per Year*
Inpatient Care
10.7%
Absenteeism
43.6%
Outpatient Care/
Partial Care
8.2%
Pharmaceutical Costs
12.5%
Decreased Productive
Capacity
18.4%
*2000 dollars
Greenberg PE, et al. J Clin Psychiatry. 2003;64:1465-1475.
Death From
Suicide
6.6%
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
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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
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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
Remission
Recovery
Relapse
Normal mood
Recurrence
Severity
Relapse
Symptoms
Response
50% improvement
Depression
Acute
Continuation Maintenance
Kupfer DJ. J Clin Psychiatry. 1991;52(Suppl):28–34.
Copyright 1991, Physicians Postgraduate Press. Adapted/Reprinted by permission.
DIFFERENTIAL
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MAJOR DEPRESSION
DYSTHYMIA
BIPOLAR, I &II DEPRESSED
PSYCHOTIC DEPRESSION
ADJUSTMENT DISORDER
DEPRESSION D/T MEDICAL COND.
DEPRESSION D/T SUBSTANCE
MEDICATIONS
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ANALGESICS ESP. NARCOTICS
STEROIDS
SEDATIVE / HYPNOTICS
ANTINEOPLASTICS
INTERFERON
Anxiety-Depression Comorbidity
The lifetime prevalence of
depression is 60% in patients with
social anxiety disorder
Anxiety
Disorders
24.9%
(lifetime
prevalence)
Major
Depressive
Up to 60% Disorder
16.2%
Overlap
(lifetime
prevalence)
The lifetime
prevalence of
depression is 57% in
patients with panic
disorder
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.
ANXIETY DISORDERS
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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
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TCA’S
MOAI’S
SSRI’S
COMBINATION AGENTS
MOOD STABILIZERS
ATYPICAL ANTIPSYCHOTICS
AUGMENTATION
TCA’S
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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
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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
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EFFEXOR (VENLAFAXINE)
SERZONE
WELLBUTRIN
REMERON
CYMBALTA
MOOD STABILIZERS
• LAMICTAL
• DEPAKOTE
• LITHIUM
ATYPICALS
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ABILIFY
ZYPREXA
GEODON
RISPERDAL
INVEGA
SEROQUEL
AUGMENTATION
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CYTOMEL (T3)
PSYCHOSTIMULANTS
LITHIUM
ATYPICALS
ELECTROCONVULSIVE
THERAPY
• 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
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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