What are some risk factors for depression?
- Neurotransmitter or hormonal imbalance
- A negative perception of life events (trauma, loss, stress)
- Medical disorders, chronic conditions, or poor prognosis
- Medication adverse reactions
- Loss of significant others
- Lack of a social support system
Who is at highest risk for suicide?
- Highest risk: elderly white males with comorbidities lacking social support
- Previous suicide attempt
- Family history of suicide
- Feeling of hopelessness
What Mnemonic is used when assessing a patient for suicide risk?
S: sex (males more successful, women attempt suicide more, less successful)
U: past attempt history
I: family history of suicide
CI: Chronic medical illnesses
D: depression, substance abuse, alcohol abuse
A: age of patient (elderly more successful, teenagers make more attempts)
L: Lethal method available (gun most lethal, followed by hanging and drug overdose)
If any signs are noted in the above assessment follow-up with the below questions should occur:
- Have you ever thought about death or dying?
- Have you ever thought that life was not worth living?
- Have you ever thought about ending your life?
- Have you ever attempted suicide?
- Are you currently thinking about ending your life?
- What are your reasons for wanting to die and your reasons for wanting to live?
What are some subjective findings associated with depression?
- Increased or decreased appetite or weight
- Decreased libido
- Sleep disturbances- insomnia or hypersomnia
- Fatigue – lack of energy
What lab/diagnostic tests should be ordered on a patient suspected of depression?
- Thyroid function tests
- Vitamin B12 and folate levels
- Blood glucose
- CBC- r/o anemia, infection
- EKG- prior to starting any tricyclic antidepressants as they may exacerbate preexisting condition
- Toxicology – drug screen, etoh levels
- Renal function
All these tests are used to rule out medical causes for depression
What 3 classes of medications are used for patients in the treatment of depression
- All anti-depressants equally effective with approximately 2/3 of patients responding to treatment
- Treatment should be continued for a minimum of 6-8 weeks to be effective.
1. Selective serotonin reuptake inhibitors (SSRIs)
- Citalopram (Celexa) or Escitalopram (Lexapro). Use cautiously in elderly! and those with liver disease; may cause QT prolongation; get baseline EKG and LFTs prior to initiation of therapy
- Sertraline (Zoloft)- PREFERRED FOR ELDERLY due to short half life
- Fluoxetine (Prozac) – long half-life (48 hours)
- SSRIs are the most commonly prescribed medications due to lower danger of overdose and less adverse effects
2. Selective norepinephrine and serotonin reuptake inhibitors,
- Mirtazapine or bupropion
- May be used for those who have not had adequate improvement with SSRIs
- Venlafaxine (Effexor or Effexor XR) – divided dosing preferred due to sedation effects
- Duloxetine (Cymbalta) – Use cautiously in elderly! And those with history of glaucoma, liver disease and alcohol abuse
3. Tricyclic antidepressants and MAO inhibitors
- Are NOT used often due to more adverse side effects and high overdose potential.
What is the most common initial presenting symptoms in the depressed older adult?