PowerPoint Presentation

At Wits End: Recognizing and Dealing with Depression and StressTerry Rabinowitz, MD, DDSContact InfoOffice: FAHC, Patrick 431

Telephone: 802-847-2112

E-mail: Terry.Rabinowitz@vtmednet.org

Objectives for TodayUnderstand what depression is and differentiate it from the bluesLearn about stress and how it may lead to depressive symptomsKnow how to minimize or prevent stressLearn some of the ways depression can be successfully treatedDepressionA rose by any other name would have just as many thornsMany Ways to Describe a Common ConditionDown in the DumpsMelancholyUnhappinessDespairSadnessSorrowHopelessnessHelplessnessDejectionGloomDownheartednessDiscouragementDespondencyGlumnessMiseryEmptyAloneAny other term you want to useVirtually all of us have been depressed at some time

Whats important is to consider duration, severity, and degree of dysfunction to determine if the depression is clinically significant*How long?How bad?How impaired?

* Of course, its always clinically significant if its me whos depressed!

7Depression FactsMajor Depressive Disorder (MDD) is quite commonReported in boys, girls, men, and womenLifetime risk of 7-12% in men and 20-25% in womenBetween 5 and 10% of patients in primary care meet criteria for MDDBut in many cases the disorder goes unrecognized and untreatedIn fact, less than 50% of persons with MDD receive treatment and almost 60% are cared for by non-psychiatrist physicians

8Facts contdDisablingCostlyDeadlyAssociated with high levels of impairment in work, social, and physical activities

Compared to persons with chronic medical disorders, those with depression have generally worse physical and social functioning and perceived current health

Total costs in us estimated to be > $70 billion per year

15% of severely depressed persons eventually commit suicide

9CausesEtiology of MDD is unknownMany believe its due to the interaction of genetic, biological, developmental, and psychosocial factorsIsnt everything?

What I mean here is that we still cant identify one or several possible causes of depression but what we can say is that when there is a convergence of favorable genetic, biological, developmental, and psychological factors, depression is a possible bad outcome. 10Common Psychological and Cognitive SymptomsLack of interest/motivationInability to enjoy things (anhedonia)ApathyIrritabilityAnxiety/nervousnessExcessive worryingReduced concentrationRuminationsAdditionally, there may be hypersensitivity to rejection or criticism, hypochondriacal concerns, low or reduced self esteem, thoughts of death or suicide, and thoughts of hurting others11Common Behavioral SymptomsCrying spellsInterpersonal friction/confrontationAnger attacks/outburstsSocial withdrawalSubstance use/abuseReduced productivityViolent/assaultive behaviorsSuicide attempts/gestures

In addition, there may be self-cutting or mutilation, development of rituals or compulsions, and reduced leisure-time activities12A Simple Way to Remember Depression SymptomsSIG E CAPS (take energy capsules)Sleep problemsInterest (loss of)/ loss of pleasureGuilt/feelings of worthlessnessEnergy (decreased)/fatigueConcentration decreasedAppetite disturbance (up or down)Psychomotor agitation or retardationSuicide thoughts/behaviors or thoughts of death

The presence of depressed mood, reduced interest or pleasure or bothit can be irritable mood in children or adolescentsand at least five of these other symptoms listed, would be indicative of major depressive disorder.13Making the DiagnosisFor a diagnosis of MDD we need:Depressed mood, loss of interest or pleasure, or irritable mood, and five of eight SIG E CAPS symptomsSymptoms must be present for at least two weeksThe symptoms cause significant distress or impairment in social, occupational, or other important area(s) of functioning

Quantifying DepressionLessons Learned # 1Many folks dont want to hear that they might be depressedWhy?ScaryStigmatizingFear of treatmentSide effects, costsWorry about loss of function

For these folks, Ive found it useful to show them how depressed they might be by using one or more objective scalesTry the PHQ-9You can find it by Googling PHQ-9It takes less than 3 minutes to complete

Filling out the questionnaire and scoring it together provides a degree of objectivity as well as allowing someone to see the numbers that might suggest depression is present.20PHQ-9Using the scale allows me to ask an objective observer to evaluate my patientIt allows my patient to see how he or she looks after removing the emotional/subjective (i.e., two people talking) component from the mixThere are other scales that are just as helpfulDepression vs. the BluesEveryone may get the blues at some time because of troubling events such as the loss of a loved one, job difficulties, money problems, family issues, traumatic events, or illnessMost cases of the blues disappear quickly and do not prevent us from finding enjoyment or being productiveDifferentiate this from depression; the feeling of sadness or loss of interest or pleasure that is present most days for at least two weeksKeep in mind though, that a case of the blues can turn into full-blown depression if symptoms last long enough and are intense enough to cause impairment

23StressToo much of a good thingEmotional Stress: Bodily or mental tension resulting from factors that tend to alter an existent equilibrium

Stress is good for you. It keeps you alert, motivated and primed to respond to danger. As anyone who has faced a work deadline or competed in a sport knows, stress mobilizes the body to respond, improving performance.Yet too much stress, or chronic stress may lead to major depression in susceptible people.

[http://www.webmd.com/depression/features/stress-depression]Stressors & Stress ResponsesSome StressorsFrustration (a goals being blocked)Conflict (uncertainty, making choices)Pressure (time pressure, emotional pressure)Some Stress ResponsesMental and Emotional SignsLack of concentration, memory lapses, anxiety, fear, panic, anger, hostility, aggressionBehavioral SignsSmoking, drinking, overeating, Type A behavior, social withdrawal Physiological SignsErratic breathing, tense muscles, aches and pain, fatigue, palpitations, sweating, dry mouth, indigestion, depressionPersonality and StressWho we are determines how we respond to stressNegativity and pessimism are related to poor healthHardiness is a personality style that may be protective against stressful effects A Negative Personality Style in Actionhttp://www.hulu.com/watch/68225/saturday-night-live-debbie-downer

Hardiness: Three CharacteristicsCommitmentA tendency to involve oneself in whatever one encountersControlThe sense that one causes the events that happen in ones life and can influence ones environmentChallengeA willingness to undertake change and to confront new activities that represent opportunities for growth

StressDepression IMind and body constantly on edgeBody's "fight-or-flight reaction is constantly onPerceived threats cause the hypothalamus, a region at the base of the brain, to set off an alarm system in the bodyThrough a combination of nerve and hormonal signals, this system prompts adrenal glands, to release a surge of hormones, including adrenaline and cortisol[http://www.mayoclinic.com/health/stress/SR00001]StressDepression IIAdrenaline increases heart rate, elevates blood pressure, and boosts energy suppliesCortisol, the primary stress hormone, increases glucose in the bloodstream and enhances brain's use of glucose It also suppresses functions that would be nonessential or detrimental in a fight-or-flight situationAlters immune system responses and suppresses the digestive and reproductive systems and growth processes[http://www.mayoclinic.com/health/stress/SR00001]This complex natural alarm system also communicates with regions of the brain that control mood, motivation, and fear

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[http://www.clinical-depression.co.uk/images/site-images/CycleComplex.gif]This Flowchart is Cool!Preventing or Minimizing StressMedicationsAcute stress and associated anxiety may require pharmacologic interventionBenzodiazepines (e.g., lorazepam, clonazepam) are the drugs of choiceBut dont use as sole intervention for chronic stressHabituation, misuse, abuse, and dependence are all possible bad outcomes. In addition, this precludes a persons learning more long-term coping skills37Non-pharmacological ApproachesDiaphragmatic breathingCan use to evoke a relaxation responseAKA cleansing breathRelaxation trainingMost effective technique for reducing effects of chronic stressCheap38Relaxation TechniquesProgressive muscle relaxationGives a sense of self-controlProduces stress reduction effectInvolves tensing and releasing large muscle groups throughout the bodyTakes about 15 minutes

Tension-Release Procedures for 16 Major Muscle GroupsGuided ImageryClose your eyesTake easy breathsGo to your happy placeImagine nice sights, sounds, and smellsMeditationBe stillConcentrate on a single stimulus, such as a word or imageIncreases oxygen consumption and blood flowTakes some work

Instrumental Coping: Behavioral Skills that can Alleviate Chronic StressEffective time managementSet priorities; break down goals into small, achievable piecesAssertiveness trainingCan help to avoid an adverse stress response and improve self-esteemAssertiveness is necessary for delegating responsibilities and reducing workload

Set priorities, break down goals into small, achievable pieces43Treating DepressionPsychotherapyHelps many with mild-moderate symptomsNo side effectsRequires some commitmentNon-habit-forming

MedicationsSeveral classes of antidepressant medications availableSSRIs and SNRIs are most commonly usedThey are quite safeSide effects may be a problemSedation, fatigue, sexual dysfunction, GI problemsOther AntidepressantsBupropionMirtazapineMAOIs

Some MisconceptionsMost patients (70-80%) recover after antidepressant treatmentActually, less than 50% show a robust response, with many showing only a partial but significant improvementTwo to four weeks of treatment is adequateActually, many folks need 5-8 weeks of treatment before showing a response Other TreatmentsElectroconvulsive Therapy (ECT)First introduced in 1938Millions of effectively treated individualsUsually reserved for persons who have not responded to several adequate antidepressant trials or who have depression with delusions or psychotic featuresLots of stigma attachedLots of One Flew Over the Cuckoos Nest ideasTranscranial Magnetic Stimulation (TMS)A noninvasive method to cause depolarization or hyperpolarization in the neurons of the brainUses electromagnetic induction to induce weak electric currents using a rapidly changing magnetic field; this can cause activity in specific or general parts of the brain with minimal discomfortTested as a treatment for various psychiatric disorders including depression Deep Brain Stimulation (DBS)Involves implantation of a brain pacemaker, which sends electrical impulses to specific parts of the brainIn select brain regions has provided significant therapeutic benefits for treatment-resistant movement and affective disorders such as chronic pain, Parkinson's disease, Insufficient evidence yet to support use for depressionStudies are currently underway at several centersTake-Home MessagesStressful situations are all around usWe cant avoid every one of themSome stress is good

Too much stress can lead to depressionThere are biochemical pathways that make this possibleThere are a number of ways we can prevent or at least minimize stressThis requires getting in touch with our feelings, accepting that we are stressed, and taking some actionIf stress cant be contained and leads to depression, there are several options for effective treatmentThe worst thing we can do at this point is to not ask for helpYou Wont Get Better If You Dont Speak Up!Thanks!