Depression, Suicide

Chapter 15 15.1 pages 527 to 562

Mood Disorders: Depression Mood is a pervasive and sustained feeling that is experienced internally and that influences a person's behavior and perception the world.

Depression

Mood can be: normal,normal, elevated,elevated, or depressed.or depressed. Healthy persons experience a wide range of  moods and have an equally large repertoire of affective expressions; they feel in control of their moods and affects.

Mood Disorder: Depression Mood disorders are a group of clinical

conditions characterized by a loss of tha that sense of control and a subjective experience of great distress.of great distress.

Patients with elevated mood demonstrate expansiveness, flight of ideas, decreased sleep, and grandiose ideas.

Patients with depressed mood experience a loss of energy and interest, feelings of guilt,,difficulty in concentrating, loss of appetite,and thoughts of death or suicide.

Other signs and symptoms of mood of mooddisorders include change in activity level,,cognitive abilities, speech, and vegetative functions (e.g., sleep, appetite, sexualfunctions (e.g., sleep, appetite, sexualactivity, and other biological rhythms).

 These disorders virtually always result in  impaired interersonal, social, and occupational functioning

DSM-IV-TR Criteria for Major Depressive Episode Table 15.1-5-6

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either

DSM-IV-TR Criteria for Major Depressive Episode

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations

Depressed mood most of the day, nearly every day,as indicated by either subjective report (e.g., feels sad or empty) or observation made by others).appears tearful)

DSM-IV-TR Criteria for Major Depressive Episode

markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day, (as indicated by either subjective account or observations by others)

significant weight loss when not dieting or weight gain (e.g., a change of more than 5% weight in a month), or decrease or increase in appetite nearly every day.

Note  In children, consider failure to make expectedIn children, consider failure to make expected weight gains.

DSM-IV-TR Criteria for Major Depressive Episode

insomnia or hypersomnia nearly every day

psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

DSM-IV-TR Criteria for Major Depressive Episode

fatigue or loss of energy nearly everyday feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every (not merely self-reproach or guilt about being sick)

diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

recurrent thoughts of death (not just fear of recurrent fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan, or a suicide attempt or a specific plan for committing suicide.

Treatment

1. Guarantee patient safety2. Complete diagnostic evaluation

of the patient3. Treatment plan that addresses:

Immediate symptoms Patient’s prospective well-being

Pharmacotherapy

Once a diagnosis has been established a pharmacological treatment strategy can be formulated

Objective: Symptom remission not just reduction

Pharmacotherapy

Major depressive disorder Most antidepressants have a lag period of 10 days to approximately 4 weeks before a therapeutic response is noted

Increasing dose will not shorten this period, it will increase the incidence of adverse reactions

Pharmacotherapy

Antidepressants 3 main classes

Selective serotonin reuptake inhibitors (SSRIs)

Tricyclic Antidepressants ( Tas) Mono amine oxidase Inhibitors (MAOIs)

All three classes work differently but all change brain chemistry to improve neurotransmission.

Pharmacotherapy

Therapeutic response Not all patients respond the same way to a medication

IF a patient fails to respond appropriately to an antidepressant, he or she may respond positively to another antidepressant, including another drug of the same pharmacologic class

Similar positive responses to drug therapy can be obtained by augmenting the original drug with a drug of a different class.

SSRIs

SSRIs are the first choice in treating depression They are preferred over TAs and MAOIs

Less damaging to the heart Minimal anticholinergic effects Minimal hypotensive effects

Fluoxetin (Prozac) 1987, became the first SSRI approved by the FDA for use as antidepressant.

Currently sertraline (Zoloft) is one of the most widely used antidepressants in the United States.

Readings- Chapter 36.29 pg 1083-1090 See tables 36.29-1 and 36.29-2

SSRIs

Pharmacokinetics SSRIs have a broad range of serum half- lives Fluoxetine has the longest half-life- 4 to 6 days; its active metabolite has a half-life of 7-9 days

SSRIs are well absorbed, peak effects range from 3 to 8 hours

All SSRIs are metabolized by the liver by cytochrome P450 (CYP) enzymes

Most interaction activities are related to inhibition of metabolism of coadministered medications.

Pharmacodynamics

SSRIs: Exert their therapeutic effects through 5HT reuptake inhibition

Higher dosages do not increase antidepressant efficacy- may increase incidence of adverse effects

Citalopram and escitalopram are the most selective of the SSRIs

Other SSRIs also have actions on norepinephrine and dopamine receptors, causing reuptake inhibition.

Therapeutic Indication

In the US all SSRIs, except fluvoxamine have FDA approval for use in the treatment of depression.

Studies have found that antidepressants with serotonin-norepinephrine activity (MAOIs TCAs) produce higher rates of remission than SSRIs Venlafaxine & mirtazapine

In the past SSRIs have been link to a slight increase in suicide ideation. However the relation remains unclear

A noted increase in anxiety and agitation has been seen in some patients

Pregnancy and Postpartum Depression

Postpartum depression affects a small percentage of mothers

68 to 100 percent relapse in pregnant patients that discontinue therapy

Evidence suggests increased rates of special care nursery admission after delivery for children of mothers on SSRIs

SSRIs are secreted in breast milk; however [plasma] levels are usually very low in mothers that are breast feeding.

Depression in the Elderly SSRIs are safe and well tolerated when used in the elderly and medically ill Little or no cardiotoxic effects Little or no anticholinergic effects

Little or no antihistaminergic effects

Little or no alpha-adrenergic adverse effects

Depression in Children

Only fluoxetine has FDA approval for use as an antidepressant in this population

Reports indicate that SSRIs can increase suicidal and violent thoughts or actions in depressed children

Children treated with SSRIs require close monitoring

Precautions and Adverse Reactions Sexual dysfunction

Most common adverse effect of SSRIs GI

Very common, mediated largely through the effects on the serotonin 5HT receptors Nausea Diarrhea Anorexia Vomiting Flatulence Dyspepsia

Precautions and Adverse Reactions Headaches

18 to 20 percent of cases CNS adverse effects

Anxiety First few weeks

Insomnia & Sedation Improved sleeping resulting from treatment of depression and anxiety

Vivid dreams

Precautions and Adverse Reactions CNS adverse effects (cont.)

Emotional blunting Inability to express emotions

Yawning Seizures

0.1 to 0.2 percent Extrapyramidal Symptoms

Anticholinergic Effects Paroxetine

Mild anticholinergic effects

Hematologic Adverse effects Can cause functional impairment of platelet aggregation Easy bruising, prolonged bleeding

Special monitoring suggested for patients on SSRIs and anticoagulants

Precautions and Adverse Reactions

Electrolyte and Glucose Disturbances SSRIs may decrease [glucose]

Careful monitoring for diabetic patients suggested

Endocrine and Allergic Reactions SSRIs can decrease prolactin levels

Mammoplasia and galactorrhea in both men and women

Various types of rashes- 4% of patients Serotonin syndrome

Concurrent administration of an SSRI with MAOI, L-Tryptophan or lithium can raise plasma [serotonin] to toxic levels

Precautions and Adverse Reactions Sweating Experienced by some patients while on SSRIs

SSRI withdrawal May exhibit withdrawal symptoms upon sudden discontinuation

Drug interactions see table 36.29-3

Suicide

Primary emergence for the mental health professional

Major public health problem Over 30,000 persons commit suicide each year in the US

More than 600,000 attempt suicide

Suicide: Risk Factors Gender

MORE COMMON IN MALE

Age 15-44

Race More common among white males

Religion Higher in Protestants and Jews than Roman Catholics

Marital Status Single, never married persons are twice more likely to comit suicide than married persons.

Divorce increases the likelihood of suicide Widows also have a higher rate

Suicide: Risk Factors cont. Social Status

The higher the person’s social status, the higher the incidence

A fall in social status also increases the risk of suicide

Occupations Both males and female physicians in the US have increase rates of suicide

Climate No significant data indicates a correlation with climate and suicide.

Physical Health The relation of physical health and illness to suicide is significant

Mental Health Almost 95% of all persons who commit suicide have a diagnosed mental illness.

Suicide: Risk Factors cont. Psychiatric Patients Psychiatric patients’ risk for suicide is 3 to 12 times that of non psychiatric patients. Depressive disorders Schizophrenia Alcohol Dependence Other Substance dependence Personality Disorders

Suicide: Treatment Decision to hospitalize a patient with suicidal ideation depends on: Severity of depression Severity of suicidal ideation Patient’s family’s coping ability Patient’s living situation Availability of social support Absence or presence of risk factors for suicide

Suicide: Pharmacotherapy Patients hospitalized can receive medication for underlying diagnoses, leading to suicide ideations or attempts: Antidepressants Antipsychotics When patients present signs of both, medications like risperidone (Risperdal) that have both antipsychotic and antidepressant effects are very useful.

Vigorous treatment should be initiated depending onunderlying disorder.

Supportive psychotherapy is also indicated. ECT may be necessary for severely depressed patients