Depressive Disorders

50% of depression cases are under-diagnosed and untreated

Of 200 people in the community
40 will present to family physician
20 have psychological symptoms
10 will be correctly diagnosed
1 will be adequately treated with anti-depressants

Substance-induced Depressive Disorder

Symptoms directly r/t physiological effect of substance

Associated with withdrawal or intoxication of substance

Alcohol, amphetamines, cocaine, hallucinogens, opioids, sedatives, anxiolytics

MDD with psychotic Features

Depressed but also experiences delusions and hallucinations

Mood congruent - put client at serious risk for self-harm/suicide

Moon incongruent - hears voices disagreeing with their current beliefs regarding self-esteem

ECT treatment of choice

MDD - Peripartum onset

50% post partum depression begins prior to delivery

may occur up to 1 year post-delivery

Predictor for bipolar disorder in later years

Etiology
Combination of hormonal, metabolic and psychosocial influences

Treatment is based on severity

4-25% developing post-partum depression in fathers

Tricyclic Antidepressants

Inhibits re-uptake of norepinephrine and serotonin

Elevates levels of neurotransmitters therefore elevating mood

May cause sedation

Anticholinergic effects (Dry mouth, blurred vision, N&V, constipation)

Amitryptyline, Desipramine, Nortriptyline, Imipramine

May take up to 8 weeks to be effective

Take as directed, usually at hs

Monoamine Oxidase Inhibitors (MAOI)

Cannot ingest tyramines as it may lead to hypertension crisis
Cheese, liver, wines, most dairy, bananas, soy sauce, beer, avocados

Watch use of over-the-counter drugs

Ie.
Phenelzine (Nardil), Tranylcypromine (parnate), isocarboxazid (marplan)

Epidemiology of Depression

Higher in females than males (2:1)

Women experience depression from age 10-midlife

Age 44-65 gender difference is less pronounced

65+ y/o have higher tendency to be depressed

Predisposing Factors

Genetics
Monozygotic twins: 37% MDD
common amongst first degree relatives

Biochemical Factors
Deficiency in neurotransmitters (Norepinephrine, serotonin, dopamine and Acetylcholine)
Serotonin plays important role in mood/anxiety/arousal/etc.

Electrolyte disturbances
Excessive sodium bicarbonate/calcium levels
Excess potassium

Hormonal Disturbances
Dysfunction in adrenal cortex
Depression associated with hyperthyroidism
Imbalance of estrogen and progesterone

Nutritional Deficiencies
Vitamin B, Vitamin C, iron, folic acid, zinc, calcium, potassium
Glucose intolerance fluctuations, abnormal fatty acids

MDD - Atypical Features

Different presentation of Symptoms

Mood reactivity, weight gain, hypersomnia, leaden paralysis, etc.

Intervention with anti-depressants may worsen symptoms

Treated with mood stabilizers
Lithium, lamotrigine, carbamazepine

Selective Serotonin Reuptake Inhibitors (SSRIs)

Blocks neural uptake of serotonin which increases levels of serotonin available

Increases serotonin therefore elevating moods

Fewest adverse and cardiotoxic effects

Decreases libido, agitation, insomnia, weight loss, seizures, increase suicidal ideation

Fluoxitine (prozac), paroxetine (paxil), Citalopram (Celexa), Sertraline (zoloft), and venlafaxine (Effexor)

Other Antidepressants

Norepinephrine dopamine re-uptake inhibitor
Wellbutrin (bupropion)

Serotonin norepinephrine Disinhibitor
Remeron (mirtazapine)

Alter neurotransmitters in the brain

Persistent Depressive Disorder Dysthymia

Similar to MDD, but milder

Chronically depressed for most of day, more days than not for at least 2 years

Premenstrual Dysphoric Disorder

Depressed mood
Excessive anxiety
mood swings
decreased interest in activities

Occurs week prior to menstruation

Becomes minimal or absent in well post menstruation

Clinical Aid Dx Depression

S	Sleep disturbances
A	Appetite changes
D	Dysphoria
A	Anhedonia
F	Fatigue
A	Agitation
C	Concentration
E	Esteem
S	Suicide

MDD - With Anxious Distress

Meets criteria for MDD but experiences anxiety symptoms

Anxiety usually present in depression

Treatment of Depression

Pharmacotherapy

Psychotherapy
Cognitive Behavioural Therapy
Interpersonal Therapy

ECT
Develops quick response

Group Therapy
WOrks better after recovery has begun

Serotonin Syndrome

Assess if pt is on high doses of SSRIs

Signs and Symptoms
Change in mental status
Diaphoresis
Lethargy
Abdominal pain
Myoclonus/tremors specific for serotonin syndrome
Hyperthermia & tachycardia
apnea

Discontinue SSRIs immediately

Benzodiazepines

Used to treat anxiety and anxiety disorders

Potentiates the action of GABA - major calming neurotransmitter in the CNS

Diazepam (valium), Alprazolam (xanax), lorazepam (ativan)

Decreases anxiety while antidepressant takes effect

Should be decreased and stopped once antidepressant becomes effective

Depressive Disorders by [deleted]