Chapter 37: Depression

In what setting can mild to moderate depression be treated in?

in a primary care settinf

How about the setting for a severe depression?

managed by a psychiatric consultant in these patients, a combination of psychotherapy and pharmacological therapy is recommended

Define Bipolar Disorder?

one or more manic or mixed episodes usually accompanied by a depressed disorder

Other common adverse effects?

sexual issues (anorgasmia, decreased libido, delayed ejaculation) weight gain, N/V, agitation

How does one routinely screen for depression ?

simple 2 question test: 1.) in the last 2 weeks, have you ever felt down, depressed, or hopeless? 2.) in the past 2 weeks, have you felt little interest or pleasure in doing things? ***positive answer to one question should precipitate additional diagnostic assessment with a PHQ-9

What is depression strongly linked to?

stress; stress systems in the brain are under the control of NE pathways

Define Situational adjustment reaction?

subsyndromal depression with a clear precipitant; will usually resolve with the removal of the acute stressor w/o meds

Define SAD?

subtype of depression, occurring with the change in season

What major side effect must be monitored in younger adults taking this medication?

the transient increase in suicidal thoughts and idealization

Define General Grief reaction?

transient period of major depression; peervasive and gernealized guilt and perisitent vegetative signs and symptoms should raise concerns for depression **consider a referral if these symptoms last more than 10 weeks

What is the first and second most common presentation in a primary care practice?

1.) HTN 2.) Depression **only 50% of patients with depression receive the appropriate treatment

What % of adults are affected by depression at some point in their lives?

15%

What side effects come with Buprorion and what is it used for?

Increased seizure risk, lower the threshold for seizures MoA: reuptake inhibitor for DA and NE

Serotonin Antagonist ?

Mertazapine >>>increases sleep improvement side effects>>>weight gain and sedation blocks 5-HT2A and used in anorexic patients with depression

Biological basis of depression?

NT chemical imbalance in the prefrontal, basal ganglia, hippocampus, and cerebellum. NE>>>involvement in the emotional drive and energy state Serotonin>>>function largely in mood DA>>>basal ganglia, associated with movement control, in other areas of the brain, DA is in control of hormone release (prolactin), the meso limbic area, which is associated with positive symptoms of schizophrenia and the meso cortical area, which can attribute to the generate of the negative symptoms of schizophrenia

TCA's?

Nortripyline older treatment for depression drug levels must be monitered due to side effects and cardiac toxicity issues (HAM blocker)

Initially, how are patients treated for major depression and or permissive depressive disorder?

SSRI (a single agent) one chosen based on cost, tolerance, and side effect profile and evidence of previous effectiveness in a 1st degree relatives

In mild to moderate depression, what herbal option works just as well?

St. John's wort, effective as an antidepressant and rarely has side efforts.

SNRI options ?

Venalfaxine>>>used for anxiety spectrum disorders side effect>>>nausea and exacerbate HTN Duloxetine>>>Effective in pain conditions and GAD

Define Minor depression?

acute depression that is less severe than major depression, causing less impairment in social and occupational functioning

Demographic and socioeconomic risk factors for depression?

advanced age, female, unemployment, lower S/E status, non-married, alcohol dependence, stressful life events

Follow up care?

always reassess the patient using PHQ-9 patient should be seen 2-4 weeks post medication therapy then again 6-8 weeks to reassess if the medication is working with a PHQ-9 on file >50% decrease in symptoms is considered a positive response to the treatment always continue the patient on the drug for an additional 4-9 months

Why is it important to rule out mania (bipolar disorder ) when starting treatment for depression?

b/c an undiagnosed bipolar disorder patient starting on antidepressants may completely unmask the frank mania

How does one diagnose clinical depression?

based on patient History and exclusion of other diagnosis, there are no tests to confirm this diagnosis once the diagnosis of depression is made, it is critical to assess severity of symptoms, functional impairment, and suicide risk **PHQ-9 is an initial screening tool, but it can be also used on patients to assess severity of symptoms and assess response to treatment

In severe depression, what PE findings would one observe in a patient?

blunted affect, delusional (possibly) must test to r/o hypothyroidism, B12 deficiency, anemia

What SSRI's have the least side effects?

citalopram and escitalopram (safe in cardiac patients) sertraline (safe in cardiac patients)>>>used in PTSD, GAD, social phobia, panic disorder

What are the greatest benefit and types of psychotherapy?

cognitive behavioral therapy problem-solving therapy interpersonal therapy

Goal of treatment on an antidepressant ?

complete remission within 6-12 weeks with continued treatment for 6-9 months (think about one year of medication) **always council patients about the 2-4 weeks delay before noticing symptom improvement

Define Permissive depressive disorder

depressed mood and/or adhedonia at least 50% of the time for a 2 year period accompanied by 2 or more vegetative or psych symptoms

Define Premenstrual Dsyphoric Disorder?

depressed mood, anxiety, and irritability prior to menses; will resolve with onset of menses

Medical risk factors for depression?

first degree relative diagnosed with depression or another psychiatric disorder, postpartum state, chronic disease (CHF, diabetes, CAD, cancer, stroke) ***depression is an independent risk factor for increase mortality in patients with CAD, cancer, stroke

What SSRI's have CYP 450 interference?

fluoxetine and paroxetine (highest risk, preg class D and weight gain)

Define Major Depressive Disorder?

for at least 2 weeks, depressed mood or loss of interest in almost all activities with at least 5 DSM-V symptoms (SIGECAPS)