Psych - Depression Flashcards
Define Depression
It is a brain disorder that affects mood, cognition, and physical well-being, and results in the deterioration of function, productivity, and interpersonal relationships; despite what colloquial language may suggest, it is not a transient mood state and is different from normal grief
Epidemiology of Depression
Affects 6.7% of adults (15 million) a year
Lifetime prevalence is 16.2%
Female : Male ratio = 2 : 1
Leading cause of disability from all mental illnesses for people between the ages of 15-44 in US/Canada
Primary cause of suicide!
Diagnosis of MDD
For a patient to be diagnosed with MDD, they must present with DEPRESSED MOOD or the INABILITY TO EXPERIENCE PLEASURE (anhedonia) and at least 4 other symptoms for at least 2 weeks –> significant weight loss/gain, sleep disturbances (too much OR not enough), fatigue, decreased ability to concentrate, psychomotor retardation or agitation, feelings of worthlessness/excessive guilt, and recurrent thoughts of death or suicidal ideation
These symptoms CANNOT BE DUE TO A MEDICATION, MEDICAL CONDITION, or BEREAVEMENT
MUST cause significant DISTRESS OR FUNCTIONAL IMPAIRMENT
MDD Details
Episodic illness that may or may not have an apparent trigger
The episodes are co-morbid with substance abuse, anxiety disorders or others; COGNITIVE DYSFUNCTION is a significant feature - pseudo dementia in severe cases!
The AGE of first onset is in teenage years, especially in females.
Patients may present with SOMATIC complaints but MAY TRY TO HIDE THEIR DEPRESSION due to social stigmas - makes diagnosis difficult!
PHQ9 is a questionnaire that can be used to screen for depression in the primary care setting
SUBTYPES of MDD
PSYCHOTIC Depression - psychotic symptoms, usually delusions are present in addition to symptoms of depression; psychotic symptoms are NOT present between episodes of depression!!
ATYPICAL DEPRESSION – when a patient experiences increased sleep and appetite, extreme fatigue, and interpersonal sensitivity (more common in women and for SOME REASON RESPONDS BETTER TO MAO INHIBITORS than others!!!)
MELANCHOLIA – a severe form of depression characterized by worse symptoms in the morning (diurnal variation), lack of reactivity, and PROFOUND ANHEDONIA; has been associated with abnormalities in the HPA axis
MEDD WITH SEASONAL PATTERN (Seasonal Affective Disorder) –> when the depressive symptoms occur during the FALL and WINTER and REMIT in the SPRING for 2 CONSECUTIVE YEARS without other changes in psychosocial variables –> responds WELL to therapy
DYSTHYMIC DISORDER
A milder form of chronic depression that lasts for 2 years with LITTLE OR NO REMISSION
These patients must have two or more of the following symptoms – poor appetite/overeating, insomnia or hypersomnia, low energy, low self-esteem, poor concentration, or hopelessness
They must also be WITHOUT A MAJOR DEPRESSIVE EPISODE in the first two years – if they do, it is likely that he patient has BOTH dysthymic and MDD!!
Diff Dx for Depressive Disorders
Have to rule these out before diagnosing MDD:
Drug induced (corticosteroids, Beta blockers, alcohol)
Endocrine Disorders
Tumors
Neurologic Disorders (MS, Wilson’s, Early dementia)
Infection - AIDS in the CNS!
Electrolyte disturbances
OR other Psych disorders!
Monoaminergic Hypothesis of Depression
Depressive states are brought upon by LOW DA and 5HT activity –> DA is the KEY NT in pleasure pathways!
Makes sense that if a patient has anhedonia, something is wrong with DA!
Other hypothesis –> HPA hypothesis (depression is a chronic form of stress that interferes with the feedback loop!)
Heritability
Many genes contribute to susceptibility to depression and gene-environment interactions can trigger depressive episodes
One of the most studied is the SEROTONIN TRANSPORTER (5HTT) which is a gene with 27 variations – the “s” allele is associated with neuroticism that correlates with a risk for depression –> 2 “s” alleles exhibits greater amygdala activation to fearful stimuli
Neuroimaging in Depression
Studies have shown that neural systems that regulate emotion and reward seeking are actually dysfunctional
AMYGDALA, MEDIAL PREFRONTAL CORTEX, and VENTRAL STRIATUM –> all of these tend to respond to NEGATIVE EMOTIONAL STIMULI and in depressed patients, they show abnormally INCREASED activity!
Other regions, associated with emotional REGULATION (dorsolateral prefrontal cortex and dorsal portions of the anterior cingulate cortex) have ABNORMALLY LOW activity in depressed patients
First line treatments for depression?
SSRI FIRST LINE!!!! But there are obviously other drugs – SNRI, TCA, MAOI, etc.
Treatments take a few weeks for therapeutic benefits to be seen (but side effects occur much earlier!!!)
STAR*D Study
Sequenced Treatment Alternatives to Relieve Depression
Goal was to assess the effectiveness of treatments in patients with MDD
Stratified into 4 levels that tested different medications or medication combinations –> if patient was not symptom free at the first level (Citalopram, an SSRI) they were placed in the next one
Study found that ONLY 30% OF PATIENTS WERE IN REMISSION AFTER TREATMENT WITH CITALOPRAM –> At Level 2, only 25% of those patients responded, and at level 3, 30%
patients may require multiple treatment strategies before achieving remission!!!*
Cognitive Behavioral Therapy
CBT works off the idea that thoughts and attitudes, and NOT external events create moods, so the treatment involves education of the patient, relaxation training, cognitive restructuring where the patients examine their thoughts and whether they make sense and then try to change them, all followed by behavior activation
Intrapersonal therapy uses biopsychosocial conceptualization and frames depression as a medical illness occurring in a social context, addressing the effect that personal relationships can have on depression
ECT & Light Therapy
ECT –> Effective treatment for psychotic depression and treatment resistant depression
It has a bad rap, but is very effective and safe, and should be considered!
Light therapy is effective in seasonal affective disorder - literally expose the patient to more lights!
