Download Document

Management of
Depression
1
Mood Disorders
Definition:

Disorders characterized by mood disturbance
( the presence of mood episodes ).

Mood episode :are distinct periods of time in which some
abnormal mood is present like depression, mania , mixedstate , or hypomania
2


Mood disorders : defined by their patterns
of mood episodes .
Major depressive disorder (MDD)
 Bipolar
disorders (BD)
 Dysthymic
disorder (DD)
 Cyclothymic
disorder (CD)
3
What causes depression???
Bio-Psycho-Social
Etiology
4
1) Biology

1.
Abnormalities in neurotransmission involving:
norepinephrine
2.
Serotonin
3.
Dopamine
4.
possibly Acetylcholine.

Genetics\familial: 1st degree relative are at much higher risk.
5
2) Psychology

Significant losses

Traumas

Abuse

neglect during development.

Loss of a parent before the age 11 is life event most
associated with development of depression.
6
3) social

recent stressful events = powerful predictor of depression.
7
Major
Depressive
Episode
during the same 2-week
period, must include at
least 1 Major + 4
Minor:
Minor criteria
Major criteria
•Significant weight loss or gain
•Insomnia or hypersomnia
•Psychomotor agitation or retardation
• Depressed mood
• Diminished interest
or pleasure
•Fatigue or loss of energy
•Feelings of worthlessness
•Diminished ability to think or
concentrate; indecisiveness
8
•Recurrent thoughts of death, suicidal
attempt or plan
Treatment of depressive disorder
Hospitalization
• at risk of: suicide , homicide ,unable to care for self
Pharmacotherapy
• A)anti-depressant
• B)adjuvant medication
Psychotherapy
• behavioral ,cognitive and family therapy , supportive and dynamic
psychotherapy
Electroconvulsive therapy (ECT)
9
A) antidepressant medications
1.
SSRI (Selective Serotonin Reuptake Inhibitors)
2.
TCA (Tricyclic Anti Depressant)
3.
MAOI (Monoamine Oxidase Inhibitors)
4.
Atypical Anti Depressant
10
1. SSRI

The most commonly prescribed anti-depressant due to:

Low incidence of side effects.

No food restrictions.

Much safer in overdose.

Mechanism of action : inhibits the presynaptic serotonin pumps increasing
serotonin availability in the synaptic clefts.

Examples:
Fluoxetine
Fluvoxamine
Sertraline
Paroxetine
citalopram
11
Escitalopram

Fluoxetine
o
longest T1/2 with active metabolites; therefore no need
to taper.
o
Safe in pregnancy, approved for use in children.

Paroxetine (most serotonin specific)
o
Highly protein bound  several drug interactions
o
Short T1/2 leading to withdrawal phenomena if not
taken consistently

Citalopram
o
Fewest drug interactions
12
SSRI

SSRI have significantly fewer side effects than TCA & MAOI due to serotonin
selectivity ( they don’t act on histamine, adrenergic, or muscarinic
receptors).
Side effects:
•Sexual dysfunction
•GI disturbance
•Insomnia
•Headache
•Anorexia, weight loss
•Akathesia
•Seizures
•Serotonin syndrome when used with MAOI
13
Serotonin syndrome
•
caused by taking 2 drugs, both of which
increase serotonin  too much serotonin in the
brain; like when used with MAOI
•
symptoms: nausea, diarrhea, palpitations,
chills, rigor, restlessness, confusion and
lethargy, Hyperreflexia
•
SSRIs should not be used at least 2 weeks
before or after the use of an MAOI .
14
Serotonin Syndrome
Treatment:

stop the drug

ABC

Gastric lavage if overdose

IV fluid and NaHCO3

Benzodiazepines (calm the pt, muscle relaxant and
prevent seizure)

B-blocker

Mirtazapine

ECT
15

SSRIs increase suicidal thinking and
behavior, this is most documented
in children and adolescents but may
be accurate for adults as well.
16
2.TCA

Inhibit reuptake of norepinephrine & serotonin in the
synapses .

Rarely used as first line due to


Higher incidence of side effects

Require more monitoring of dosing

Can be lethal in overdose
Usually started on low dose, then increase to the
therapeutic dose (that to avoid the anti-cholinergic side
effects).
17
2.TCA

Examples
Imipramine
Amitriptyline
Desipramine
Trimipramine
Clomipramine
Nortriptyline
Doxepin
18
2.TCA
 Side Effects
 Anti-histamine properties ( sedation)
 Anti-adrenergic properties ( arrhythmias,
tachycardia, orthostatic-hypotension)
 Antimuscarinic effects ( dry mouth, constipation,
urinary retention, blurred vision)
 Weight gain
 Major complications 3Cs ( Convulsion, Coma,
Cardiotoxicity).
19
20

TCAs MOST LEATHAL IN OVERDOSE

TCAs prescribed for bed wetting in
children so you should be careful
while prescribing the dose
21
3.MAOI

Increase the availability of biogenic amines ( serotonin,
norepinephrine, tyramine, dopamine ) at synapses by
irreversible inhibition of oxidase enzymes (MAOI-A,
MAOA-B).

Not used as first line due to side effects.
22
3.MAOI

Examples:
Phenelzine
Tranylcypromine
Isocarboxazid
23
24
3.MAOI
•Side Effects
•Common side effects ( orthostatichypotension, drowsiness, weight gain,
sex-dysfunction, dry mouth, sleepdisturbances).
•Serotonin syndrome if used with SSRI,
•Hypertensive crisis, especially if used
with sympathomimetcs or tyramine rich
foods (cheese, chicken liver, cured
meats).
25
4. Atypical Anti-depressents
SNRI
serotonin /
norepinephrine
reuptake
inhibitors
Venlafaxine
NDRI
SARI
NASA
norepinephrine
/ dopamine
reuptake
inhibitors
serotonin
antagonist and
reuptake
inhibitor
norepinephrine
and serotonin
antagonists
Bupropine
Nefazodone
trazodone
26
mirtazapine
SNRIs
venlafaxine

it increases serotonin and norepinephrine availability in the synaptic
cleft.

Venlafaxine is especially useful in treating refractory depression.

S\E: sexual dysfunction, headache, insomnia ,anorexia.

Can increase blood pressure as side effect.
27
NDRIs
Bupropion
•
binds selectively to the dopamine transporter, but its
behavioral effects have often been attributed to its
inhibition of norepinephrine reuptake. It also acts as
a nicotinic acetylcholine receptor antagonist
•
NO sexual side effects as in SSRI.
•
Increase risk of seizures and psychosis at high dose.
•
Contraindicated in patients with seizure or active eating disorders,
and in those currently on MAOI.
•
Also used in smoking cessation, and seasonal affective disorder.
28
SARIs
Nefazodone

Especially useful in treatment of refractory major depression, major
depression with anxiety.

S\E: include nausea, dizziness , orthostatic hypotension, cardiac
arrhythmia, sedation and priapism and hepatotoxicity.
29
NASAs
mirtazapine

Useful in treatment of refractory major depression .

S\E:sedation ,weight gain , dizziness , tremor ,blurred vision .

Rarley allergic reaction, edema, fainting, seizures, bone marrow
suppression, myelodysplasia, and agranulocytosis.
30
B) Adjuvant medications

Stimulants (methylphenidate) still need studies

Antipsychotics useful in patient with psychotic features

Liothyronine(T3), levothyroxine(T4), lithium, l-tryptophan maybe added to convert
nonresponding patient to responders
31
psychotherapy

Behavioral therapy

Cognitive therapy

Supportive therapy

Psychoanalysis therapy

Family therapy

Maybe used alone or with pharmacotherapy

Psychotherapy and antidepressant are useful in treating
dysthymic
32
Electroconvulsive therapy

Indicated id the patient is unresponsive to
pharmacotherapy , or cant tolerate the medications
(pregnancy) ,or if we need to decrease symptoms fast
(suicide risk )

It’s a safe therapy and we might use it with
pharmacotherapy

Before we start the ECT session we give the patient
atropine followed by anesthesia and muscle relaxant
then a generalized seizure is induced by passing a
current of electricity across the brain

The seizure lasts <1 minute
33

Approximately eight treatments are administered over a
2-3 week period

Side effects : retrograde and anterograde amnesia ,
headache , nausea, muscle soeness
34
Have a pleasant day 
35