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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 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 • • • • • • 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 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 • • • • • • • 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 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 • • • • • • • • 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 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 • • • • 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