What is the most common type of psychiatric disorder?
depressive disorders
Which socioeconomic class is more likely to be depressed?
depression affects all socioeconomic classes equally
Is depression more prevalent in men or women?
women! 21%
men (13%)
What percentage of suicides are due to depression?
60%
What are the main "costs" of depression?
direct costs - treatment
indirect costs - loss of productivity
lost earnings - suicide
What are the risk factors for depression?
female gender
age 18-44
family history
unmarried or divorced
multiple life stressors
What is the Holmes-Ray social readjustment scale?
a ranking of the life stressors
What are some of the etiological factors associated with depression?
biogenic amines
neuroendocrine diseases
genetic predisposition
psychosocial stress
What type of diseases may initially present as depression?
neuroendocrine diseases
What part of the brain are the biogenic amines found?
prefrontal cortex and limbic system
What are the biogenic amines?
norepinephrine
serotonin
dopamine
GABA
What are the neuroendocrine hormones that play a role in depression?
ACTH
TSH
GH
If a first degree relative has depression, how much more likely are you to have depression?
1.5-2.5x more likely
What is the concordance rate in monozygotic twins for depression? Dizygotic twins?
monozygotic = 50%
dizygotic = 10-25%
What are the physical signs and symptoms of depression?
5% weight loss or gain
psychomotor agitation
sleep disturbance
fatigue, energy loss
vague somatic symptoms
What are the psychological symptoms of depression?
worthlessness
anhedonia
depressed mood nearly always
cognitive impairment
thought of death/suicide
T or F: depression in the elderly is uncommon
FALSE - 15% over age 65 have depression
What is depression in the elderly commonly caused by?
medical illness
Which age group and gender has the highest prevalence of depression?
females over 80 years old
What might depression be misdiagnosed as in the elderly?
dementia
What are risk factors for depression in the elderly?
prior depression or family history
chronic medical illnesses
isolation, no social support
financial stress
female gender
Are adolescent boys or girls more likely to have depression?
boys
What are some of the symptoms of childhood depression?
excessive clinging to parents
poor school grades or phobia
failure to gain weight
substance use
antisocial behavior: truancy, fighting, running away, crimes
What are some problems associated with depression in children?
conduct disorder
substance use
school failure
poor family and peer relations
At what age can children consciousness attempt to commit suicide?
age 5 - have a concept of death being final
How long do symptoms need to occur in adults or children to be diagnosed with depression?
need 5 symptoms for a duration of two weeks
What are the TWO necessary symptoms that need to be present to diagnose adults with depression?
1. depressed or irritable mood
2. anhedonia
What is the one symptom that needs to be present in order to diagnose a child with depression?
depressed or irritable mood
What are the 9 depression criteria?
1. Sleep disturbance
2. Appetite loss, weight loss
3. Depressed mood, crying
4. Anhedonia
5. Fatigue, lack of energy
6. Anxiety or agitation
7. Cognitive disturbance
8. Esteem feeling worthless
9. Suicide thoughts or attempts
What are some of the medical conditions that may cause depression?
drugs and toxins
cancers and neoplasms
endocrine diseases
collagen vascular disease
substance use
CNS diseases
What is one of the first lab studies you should order when you suspect a person has depression?
thyroid function panel
Which metabolic diseases might tend to mimic depression or have depressive symptoms?
hypothyroidism
cushing's
addison's
What percentage of stroke patients have depression? What is this due to?
40-50% of stroke patients have depression
this is due to the BIOLOGY of the stroke
T or F: the severity of depressive symptoms correlates with the severity of the stroke
FALSE
Which type of symptoms are more common in depressed post-stroke patients?
vegetative symptoms (appetite, thirst, sexual drive, sleep)
psychological symptoms are less common
What are common medical symptoms in the elderly that might mimic depression or lead to depression?
hypothyroidism
stroke
cancer
arthritis
heart disease, HTN
parkinson's disease
DM
What are some OTC medications that may cause depression?
sleeping aids
benadryl
tagamet
antihistamines
What are the prescription medications that may cause depression?
steroids
antihypertensives
narcotic analgesics
parkinson medications
What are the most common medications used to treat depression?
1. SSRIs
2. TCAs
3. MAOIs
4. heterocyclic antidepressants
Why are SSRIs the first line treatment for depression?
less bothersome side effects
faster response
once day dosing
less lethal in an overdose
How will medication levels be affected if a patient lacks the enzyme CYP 2D6?
level of the drug will be higher because it is metabolized slower (7-10% of caucasians lack the enzyme)
What are the side effects of paxil?
sexual dysfunction
urinary frequency
dizziness, sweating
fatigue
What are the side effects of prozac?
headaches and aggitation (may have weight gain also and persistent GI disturbances)
What are the side effects of luvox?
nausea
drowsiness
anorexia
constipation
What are the side effects of zoloft?
diarrhea
tremors
dry mouth
What is SSRI discontinuation syndrome?
seen with paxil, luvox, effexor, zoloft
caused by rapid dose reduction or complete cessation of SSRI
How do you treat SSRI discontinuation syndrome?
resuming SSRI or using fluoxetine
What are the physical symptoms of SSRI discontinuation?
dizziness, vertigo, ataxia
lethargy, myalgias
parathesias, tremors
migraine auras
What are the psychological symptoms of SSRI discontinuation?
anxiety, agitation
crying spells, depressed mood
vivid dreams
concentration, memory difficulty
depersonalization
(looks a lot like depression returning)
What are the techniques for discontinuing an SSRI?
taper medication slowly
25% reduction for one month
reduce by 1/2 dose every three to four days after
What is the MOA of TCAs?
decrease norepi and serotonin reuptake
block ACTH receptors
block histamine receptors
What are some TCA side effects?
dry mouth
blurred vision
constipation
urinary retention, impotence
increased narrow angle glaucoma
sedation
weight gain
N/V
hypotension
What is CNS anticholinergic syndrome?
seen with TCA usage
confusion, delirium, more likely to occur with co-administration of antipsychotics
Which depression medication is okay to combine with an antipsychotic? Which is not?
okay = SSRI
not okay = TCA
Which class of depression medications affect the heart? In what way?
TCAs
tachycardia
prolonged QT interval
Depressed ST segment
flattened T waves
Which type of medication lowers the seizure threshold?
TCA - specifically in children, epilepsy and patients with brain tumors
What symptoms may occur in a TCA overdose?
decreased myocardium contraction
hypotension
tachycardia
What are the symptoms of anticholinergic rebound syndrome?
N/V/upset stomach
lightheadedness, headache
increased salivation
urinary incontinence
diaphoresis
diarrhea
treatment is slow tapering
What is TCA induced mania?
manic symptoms emerge during antidepressant treatment
(can also be seen with some SSRIs)
Which medications will not have induced mania?
fluoxetine and bupropion
What type of medication are trazodone and nefazodone?
heterocyclics
What are the available MAOIs and what are they also used to treat?
also used to treat Parkinson's
Nardil
Parnate
Eldepryl
Why are MAOIs not commonly used?
they cause a lot of side effects
What are the side effects of MAOIs?
hepatotoxicity
orthostatic hypotension
weight gain
confusion
pyridoxine deficiency tremors
orgasm dysfunction
persistent insomnia
hypertensive crisis
Which medications should you NOT use with MAOIs?
TCA, SSRI, OTC cough medicine, demerol
Which type of medication might cause a tyramine hypertensive crisis?
MAOIs
What are symptoms of a tyramine hypertensive crisis?
headache, stiff neck
N/V
diaphoresis
What is the treatment for a tyramine hypertensive crisis?
regitine
thorazine
ER admission
T or F: RIMAS are not available in the US
TRUE
What laboratory tests should be ordered when a person presents with depression?
baseline EKG
LFT
thyroid function tests
pregnancy test
CBC with differential
What is an antidepressant trial?
8 weeks long
look for improvement in 3-4 weeks
switch drug if there is no response
How is depression medication efficacy measured?
1. Beck Depression Inventory
2. Zung Rating Scale
3. Hamilton Rating Scale for Depression
4. Multiscore Depression Inventory for Children
What are the different responses to an antidepressant trial?
full response
partial response
no response
manic switching
In the depression medication trial, when might manic switching occur?
usually happens very early in the trial (1-2 weeks)
What are the symptoms of manic switching?
no sleep
no appetite
feelings of grandiosity
How long is depression normally treated with medication?
6-9 months
What is ECT used for?
unresponsive major depression
psychosis of bipolar disorder
medically complicated depression
dysthymia
intolerance/failure of drug therapy
proven response to ECT in the past
When is ECT a first line treatment?
severe depression
during pregnancy
delirium with depression
How many sessions does one typically undergo ECT treatment?
8 sessions that take about 5 minutes each
What are the contraindications for ECT therapy?
brain disease
severe cardiac disease
unstable medical condition
retinal detachment
What is transcranial magnetic stimulation?
low frequency magnetic pulse applied to prefrontal cortex
neuron depolarization causes increase in monoamine levels
patient is awake
T or F: the patient is asleep in both ECT and transcranial magnetic stimulation
FALSE
the patient is only asleep in ECT
T or F: both ECT and transcrainal magnetic stimulation result in a seizure
FALSE
only ECT results in a seizure
What type of depression warrants a referral to psychiatry?
severe depression
failure of two antidepressant trials
multiple medications
depression with psychosis
suicidal behavior
serious medical conditions