Depression Flashcards
lifetime prevalence of depression?
- major depression - US 17%
- persistent depressive disorder 3% (no remission of depression)
Epidemiology of depression?
- gender: 10-25% in women 5-12% in men puberty to 50: women 2x rate of men after 50 - men = women - age: prevalence decreases with age becomes more common in odler adults with greater burden of medical illness assist. living, skilled nursing, acute/chronic medical conditions esp high risk
Pathogenesis of depression?
- group of heterogenous disorders that are phenotypically similar
- final common pathway of diff disease processes that occur across biopsychosocial continuum
- genetics
- early life adversity
- social factors
- psychological factors
- secondary depression (gen medical disorders/meds/substance abuse)
pathogenesis - genetics?
- genes+enviro+enviro altered gene expression
- no specific genes linked to risk - mult small genetic effects
- epigenetics: changes in expression of genes caused by early life experiences or chronic stress
- concordance rate for major depression in monozygotic twins: 37%
pathogenesis - early life adveristy?
- predisposes to major depression by alt sensitivity to stress and response to negative stimuli
- early life stress: hyperactive corticotropin releasing factor cells in hypothalamus - increased stress response (HPA axis)
- stress responses can be set for life and modify the activation of certain genes (epigenetic) and transmitted to offspring
pathogenesis - social factors?
- may lead to depression onset or lead to depressive episodes
- isolation
- poor social relationships
- criticism from family members (expressed emotion)
- depression in social networks
- influence sxs expressed and willingness/ability to access care
pathogenesis - psychological factors?
- cognitive/behavioral: negative/distorted patterns of thinking predispose to depression
these patterns worsen in depressed person - personality:
neuroticism - anxiety, moodiness, envy, frustration, loneliness - respond poorly to stressors, interpret ordinary situations as threatening, and minor frustrations as hopelessly difficult - psychodynamic: early losses, interpersonal relationships
Pathogenesis - secondary depression?
- general medical conditions
- meds
- drugs of abuse
Medical conditions that can lead to depression?
- sleep apnea
- hypothyroidism/vit D def/diabetes
- chronic pain and opioid use
- stroke
- heart disease - ischemic, HF, cardiomyopathy
- parkinsons
- MS
- epilepsy
- head injury
- cancer
- COPD
- dementia
- HIV/neurosyphilis
Meds that can cause depression?
- interferon
- corticosteroids - more likely to cause bipolar
- benzos/opioids
- varenicline (chantix)/BBlockers
Drugs of abuse that can cause depression?
as you are withdrawing: - PCP - amphetamines - cocaine - marijuana during intoxication: - sedative-hypnotics - alcohol - opiates - steroids
Neurobio of depression? - structure and fxn?
- altered brain structure and fxn: unknown if alterations represent cause or consequence of depression (mult episodes of depression causes structural changes in your hippocampus)
structure:
-increased ventricular - brain ratio - smaller frontal lobe volumes
- smaller hippocampal volumes
- number/density/size of neurons and glial cells are abnormal
fxn:
-NTs - abnorm fxning
monoamines (serotonin, NE, dopamine), GABA, glutamate
- HPA axis: excess excretion of glucocorticoids may lead to suppression of neurogenesis and hippocampal atrophy
- abnormal neuronal networks
- sleep/circadian rhythms: decreased REM latency and slow wave sleep inflammation - higher levels of inflammatory markers
3 diff manifestations of sxs of major depression?
- psychological
- neurovegetative
- psychomotor/physical
Psychological sxs of major depression?
- depressed mood (dyphoria)
- numbness
- anhedonia - inability to experience joy
- decreased interest
- irritability/anxiety
- guilt/worthlessness
- suicidal ideation
neurovegetative sxs of major depression?
- appetite - wt loss
- sleep - can’t sleep, wake up 3 am
- energy
- concentration
Pyschomotor/physical sxs of major depression?
- psychomotor: retardation agitation - physical: aches/pain weakness/malaise GI distress
Qualifers that rule in depression?
- sxs occur in same 2 weeks
- most of day nearly every day
- distress or impairment
- R/o substances/general med condition
- R/o bereavement
subtypes of depression?
- anxious
- atypical
- catatonic
- melancholic
- mixed features
- peripartum
- psychotic
- seasonal
Subcategories of depression?
- bipolar
- secondary:
medical illness
meds
drugs of abuse
comorbid psych conditions?
1. anxiety disorders: generalized anxiety panic disorder OCD PTSD 2. substance abuse
SIGECAPS?
S: sleep I: interest G: guilt/worthlessness E: energy C: concentration A: appetite P: psychomotor disturbance S: suicidal ideation
Depression eval?
- chronology of current sxs
- sxs occur in same 2 weeks
- most of day nearly q day
- distress or impairment
- prior hx of depressive episodes
- impact of episode on occupational and interpersonal fxning
- alleviating and aggravating factors (stressful life events)
- address comorbidity (substance, illness, meds, psych)
- eval for mania/hypomania
- distinguish major depression from persistent depressive disorder (dysthymia) - 2 yrs w/o s free interval of 2 months
- suicide risk
depression eval cont. - History component?
- general medical illness
- family hx: depression, suicide, psychosis, bipolar
- social hx: interpersonal, occupational, financial stressors - sources of support, assessment of family/relationship dynamics
depression eval cont. - exam and labs?
- complete physical and neuro exam
- MMSE
- toxicological screen
- lab screen: CBC, TSH, LFTs, Chem7, Ca, B12, folate, HIV
- brain imaging (psychosis or neuro findings)
- +/- EEG, LP (psychosis or neuro findings)
Psychotic features of depression?
What ?s should you ask pt?
- delusions
- hallucinations
- disordered thought
- up to 20% of pts
- markedly higher suicide risk
?s:
does your mind ever play tricks on you?
do you ever hear things/see things?
do you ever feel like people are out to get you?
Suicide RFs?
- S: sex (male)
- A: age- elderly or adolescent
- D: depression
- P: prev. suicide attempts
- E: ethanol abuse
- R: rational thinking loss
- S: social supports lacking
- O: organized plan - suicide
- N: no spouse-div, wid, single
- S: sickness (physical illness)
How to ask about suicide attempts?
- organized plan?
- access to lethal means?
- previous attempts?
- family hx?
- non-suicidal self injury
- previous attempts: who, what, when, where, why, how? - what exactly did you do? - was it planned? - did you tell anyone? - risk/rescue
