Depressive Disorders50% 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 DisorderSymptoms directly r/t physiological effect of substance | Associated with withdrawal or intoxication of substance | Alcohol, amphetamines, cocaine, hallucinogens, opioids, sedatives, anxiolytics |
MDD with psychotic FeaturesDepressed 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 onset50% 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 AntidepressantsInhibits 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 DepressionHigher 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 FactorsGenetics 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 FeaturesDifferent 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 AntidepressantsNorepinephrine dopamine re-uptake inhibitor Wellbutrin (bupropion) | Serotonin norepinephrine Disinhibitor Remeron (mirtazapine) | Alter neurotransmitters in the brain |
| | Persistent Depressive Disorder DysthymiaSimilar to MDD, but milder | Chronically depressed for most of day, more days than not for at least 2 years |
Premenstrual Dysphoric DisorderDepressed 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 DepressionS | Sleep disturbances | A | Appetite changes | D | Dysphoria | A | Anhedonia | F | Fatigue | A | Agitation | C | Concentration | E | Esteem | S | Suicide |
MDD - With Anxious DistressMeets criteria for MDD but experiences anxiety symptoms | Anxiety usually present in depression |
Treatment of DepressionPharmacotherapy | Psychotherapy Cognitive Behavioural Therapy Interpersonal Therapy | ECT Develops quick response | Group Therapy WOrks better after recovery has begun |
Serotonin SyndromeAssess 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 |
BenzodiazepinesUsed 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 |
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