Depressive Disorder Sept. 14 e
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Transcript of Depressive Disorder Sept. 14 e
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DEPRESSIVEDISORDERS
Ponciano Z. Jerez Jr., MD, FPPA(Life)
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SADvs
DEPRESSED
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Depression:Common Symptoms
MOOD PSYCHOLOGICAL PHYSICAL
Prolonged unhappiness
Loss of interest or pleasure
Hopeless
Helpless
Guilt / Negative attitude to self
Unable to think clearly / quickly
Poor concentration / memory
Thoughts of death or suicide
Agitation or slowing down
Tiredness / Lack of energy
Sleep problems
Weight loss / increase
Disturbed appetite
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FACTS ABOUT DEPRESSION Lifetime prevalence rate of 10 - 25% for females and 5
- 12% for malesHormonal, differing psychosocial stressor and
learned helplessness Learned helplessnessDiffering psychosicial stressors
Highest rates between 25 - 44 years old
Increasing in people less than 20 years old
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Genetic Factors10 25% risk for a child if one parent has mood
disorder1.5 - 3x greater risk in patients with a (+) family
history.Herditability is about 40-50% specially in severe
depressionMonozygotic or identical twins double risk vs
dizygotic or fraternal twin studies
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Psychosocial Factors such as Life events and Environmental Stress
Losing a parent before the age of 11 Loss of spouseUnemploymentRecent life events are the most powerful
predictors of the onset of a depressive episode
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Diathesis model Individual vulnerability
Cognitive theory (triad of depression)1. view about self (negative self-percept)2. about the environment (hostile and
demanding world)3. about the future (suffering and failure)
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Biologic factorsProbable cause: depletion of serotonin and
noradrenaline at the synapses In relation to genetics, one gene isolated 5HTT
which helps regulate neurotransmitter -Serotonin
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Biochemical Basis of Depression
The Amine Hypothesis:
Depression arises as a consequence of adisturbance of one or more of the biogenicamine neurotransmitters in the brain. This formsthe basis of the monoamine hypothesis ofdepression, which suggests that a relative deficitin NA, 5HT and DA is responsible for thesymptoms of depression.
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Biochemical Basis of Depression
The amine hypothesis postulates that thechanges in mood (possibly linked to a deficitin 5-HT), deficit in drive and motivation(possibly linked to DA and NE) are the resultsof hypoactivity of these neurotransmitters.
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The Amine Hypothesis
Antidepressants act on various biochemicalprocesses in the brain by which the amineneurotransmitters prolong their physiologicactions and thereby attenuate the mainsymptoms of depression.
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Neurotransmitters and Clinical Symptoms
NORADRENALIN
DOPAMINE
SEROTONIN
APATHY
LACK OF
INTEREST
TENSE
IRRITABLE
LACK OF
PLEASURE
ANXIETY
MOOD
THOUGHTS
LACK OF
ENERGY
APPETITE
SEX
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The Role of Noradrenalin
There is accumulating evidence that the NA systemmodulates drive and motivation, aside fromlearning and memory
Noradrenergic Pathways
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The Role of Serotonin
The serotonergic system modulates impulsivenessand mood.
Serotonergic Pathways
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Dopaminergic Pathways
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Depressive Disorders
Major Depressive Disorder
Disruptive Mood Dysregulation Disorder
Dysthymic Mood Disorder
Premenstrual Dysphoric Disorder
Substance/Medication-Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition
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Major Depressive Disorder
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Major Depressive Disorder
Criterion symptom must be present nearlyeveryday
Insomnia and fatigue- usual presentingcomplaint
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9% of patients in primary care settings
30% of acutely hospitalized adults
40% of older patients in long-term care
80% of severely depressed patients think of suicide
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Depression in Primary Care Setting
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Neurotransmitters and Clinical Symptoms
NORADRENALIN
DOPAMINE
SEROTONIN
APATHY
LACK OF
INTEREST
TENSE
IRRITABLE
LACK OF
PLEASURE
ANXIETY
MOOD
THOUGHTS
LACK OF
ENERGY
APPETITE
SEX
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Major Depressive Disorder:
DSM Criteria
A. 5 or more of the following symptom
2-week period either depressed mood or loss of interest
1. Sad, depressed mood, most of the day, nearly every day for two weeks
2. Loss of interest and pleasure in usual activities3. Difficulties sleeping4. Shift in activity level 5. Changes in appetite and weight loss/gain6. Loss of energy, fatigue7. Negative self-concept, self-blame, guilt, worthlessness8. Difficulty concentrating 9. Recurrent thoughts of death or suicide
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B. Symptom cause significant distress or impairment in social and occupational or other areas of functioning
C. Not due to substance abuse or any medical condition
D. Occurrence of major depressive episode is not due to other psychotic disorder
E. No hypomanic or manic episode
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Associated features
Tearfulness
Irritability
Brooding
Obsessive rumination
Anxiety
Phobias
Separation anxiety(children)
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Prevalence(Major Depressive disorder)
18-29 years old > 60 years old
Female > male
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Disruptive Mood Dysregulation Disorder
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Disruptive Mood Dysregulation Disorder
Chronic, severe persistent irritability
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Disruptive Mood Dysregulation Disorder
A. Severe recurrent temper outbursts manifested behaviorally that are grossly out of proportion in intensity or duration to the situation
B. Temper outburst inconsistent with developmental level
C. Temper outbursts occur 3x or more per week
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Disruptive Mood Dysregulation Disorder
D. Mood between temper outbursts, persistently angryor irritable most of the day and observable by other
E. Criteria A-D present for 12 or more months
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Prevalence(Disruptive Mood Dysregulation Disorder)
Male > Female
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Dysthymic Disorder
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Dysthymic Disorder
presence of depressed/irritable mood that haspersisted at least 2 years (adults) 1 year (children)
The main feature
anhedonia the inability to experience pleasure, social
withdrawal, low self-esteem
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Dysthymic mood disorder
A. Depressed/irritable mood
B. Presence of two of the following: Appetite disturbance Sleep disturbance Low energy/fatigue Poor concentration of difficulties making decision Feelings of hopelessness
C. Present for two year period (one year in children and adolescents)
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Premenstrual Dysphoric Disorder
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Essential expression of mood la bility
Irritability
dysphoria,
anxiety
symptoms that occur repeatedly during the pre menstrual phase
Premenstrual Dysphoric Disorder
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Premenstrual Dysphoric Disorder
A. In the majority of menstrual cycles, at least 5symptoms must be present in the final weekbefore the onset of menses, start to improvewithin a few days after the onset of menses, andbecome minimal or absent in the weekpostmenses
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B. 1 or more of the following symptoms must be present:
Marked affective labilityMarked irritability or anger or increased
interpersonal conflictsMarked depressed mood, feelings of
hopelessnessMarked anxiety, tension, and/or feelings of being
keyed up or on edge
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C. One (or more) of the following symptoms must additionally be present, to reach a total of 5 symptoms when combined with symptoms from Criterion B above.
1. Decreased interest in usual activities
2. Subjective difficulty in concentration
3. Lethargy, easy fatigability, or marked lack of energy
4. Marked changes in appetite; overeating;
5. Hypersomnia or insomnia
6. Sense of being overwhelmed or out of control
7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of bloating or weight gain
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D. The symptoms are associated with clinicallysignificant distress or interference with work, school,usual social activities, or relationships with others
E. The disturbance is not merely an exacerbation ofthe symptoms of another disorder, such as majordepressive disorder, panic disorder, persistentdepressive disorder (dysthymia), or a personalitydisorder (although it may co-occur with any of thesedisorders).
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F. Criterion A should be confirmed by prospectivedaily ratings during at least two symptomatic cycles.(Note: The diagnosis may be made provisionallyprior to this confirmation.)
G. The symptoms are not attributable to thephysiological effects of a substance or anothermedical condition
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Associated Features Supporting Diagnosis
Delusions and hallucinations late luteal phase of the menstrual cycle
premenstrual phase risk period for suicide
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Risk and Prognostic Factors
Women who use oral contraceptives fewer premenstrual complaints than do women who do not
use oral contraceptives
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Functional Consequences of Premenstrual Dysphoric Disorder
marked impairment in the ability to function socially or occupationally in the week prior to menses
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Substance/Medication-Induced Depressive Disorder
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Substance/Medication-Induced Depressive Disorder
A.
A prominent disturbance in characterized bydepressed mood or markedly diminished interest
or pleasure in all, or almost all, activities
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Substance/Medication-Induced Depressive Disorder B.
Theres evidence:The symptoms in Criterion A developed during or
soon after substance intoxication or withdrawal orafter exposure to a medicationThe involved substance/medication is capable of
producing the symptoms in Criterion A.
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Substance/Medication-Induced Depressive Disorder
C.The disturbance is not better explained by a
depressive disorder that is not substance /medication-induced.
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Substance/Medication-Induced Depressive Disorder
D. symptoms preceded the onset of the
substance/medication use symptoms persist for a substantial period of time
(e.g., about 1 month) after cessation of acutewithdrawal or severe intoxication
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Substance/Medication-Induced Depressive Disorder
E.The disturbance does not occur exclusivelyduring the course of a delirium
The disturbance causes clinically significantdistress or impairment in social,occupational, or other important areas offunctioning
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Depressive Disorder Due to Another Medical Condition
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Depressive Disorder Due to Another Medical Condition
A.A prominent and persistent period of depressed
mood or markedly diminished interest or pleasurein all, or almost all, activities that predominates inthe clinical picture
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B.There is evidence from the history, physical
examination, or laboratory findings that thedisturbance is the direct pathophysiologicalconsequence of another medical condition.
Depressive Disorder Due to Another Medical Condition
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C.The disturbance is not better explained by another
mental disorder (e.g., adjustment disorder, withdepressed mood, in which the stressor is a seriousmedical condition).
Depressive Disorder Due to Another Medical Condition
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D.The disturbance does not occur exclusively during
the course of a delirium
E.The disturbance causes clinically significant distress
or impairment in social, occupational, or other important areas of functioning
Depressive Disorder Due to Another Medical Condition
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Major Classes of Anti-Depressant Drugs
Monoamine oxidase inhibitors: First effective antidepressants to be used clinically but are
now used infrequently
Tricyclic Antidepressants: General uptake inhibitors of biogenic amines that inhibit the
uptake of both 5-HT and NA, and are probably the most effective drugs for patients who are severely depressed
Selective Serotonin Reuptake Inhibitors The most commonly used anti-depressants that inhibit the
reuptake of serotonin
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Seven Different Types of Anti-depressants (Stephen Stahl)
Tricyclic antidepressants
Monoamine oxidase inhibitors
Selective serotonin reuptake inhibitors
Serotonin-norepinephrine reuptake inhibitors
Serotonin-2 antogonism/reuptake inhibitors
2 antagonism + serotonin reuptake inhibition
Selective norepinephrine and dopamine reuptake inhibitors
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SummaryMany of the side effects of antidepressants are
attributable to the action of the drug on receptorsthat are associated with their antidepressantactions (such as the adrenoreceptors, muscarinicreceptor and histaminic receptors).
Some side effects are an inevitable consequence ofactivation of the serotonergic system and includethe neurological, sexual, and GI side effects. Sucheffects occur with the SSRIs, SNRIs and MAOIs.
Dietary interactions are largely confined to the non-selective MAOIs.
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Mood has to be controlled. Otherwise, its your master.
Thank you!