Depression - Epidemiology
Affects >78 million in the US
15% lifetime risk of having major depressive disorder (MDD)
4th most common reason to visit primary care
Female > Male (2:1)
Depression - Pathophysiology
Impaired synthesis and/or metabolism of the neurotransmitters norepinephrine, serotonin, dopamine (possibly others)
Genetic basis-1.5-3.0 more common among those with an affected 1st degree relative
Serotonin produces calmness and relaxed states
Dopamine
Depression - Risk Factors
-Predominant age: 1st onset usually in late 20s (earlier in women than men)
-Elderly (�65)
-History of behavioral disorders
-Presence of chronic disease(s)
-Recent myocardial infarction/stroke
-Strong family history (depression, bipolar, suicide, alcoholi
Depression - Screening and Prevention
Screening:
US Preventive Services Task Force (USPSTF) advise screening
Prevention:
Know protective factors:
Regular Exercise
Social Support
Healthy Diet
Avoiding Substance Abuse
Depression - Differential Diagnosis
Medication use, abuse or withdrawal
Substance use, abuse or withdrawal
Nutritional deficits-(B12), B6, B8
Bipolar
Physical Illness-endocrine, metabolic, adrenal, liver or renal failure, neurologic disorders, infectious disease, malignancy
Grief
Other psyc
Depression - Subjective Data
-Screening is important
-Neurovegatative symptoms
-Bodily complaints - Low energy, aches
-Psychosocial - Current home environment, living situation
-Psychiatric (self and family)
-Suicidal ideation - intent on hurting self, if plan is present then it is a
Depression - SIG E CAPS
Questions to ask during screening
S is your sleep disturbed
I have you noted a loss of interest in usual activities and/or loss of libido
G are you feeling guilty or thinking badly about yourself
E have you noticed a decrease in your energy level
C have y
Depression - Objective Data
-Physical exam is decided based on symptoms but needs to be inclusive
-Bodily complaints tend to be out of proportion to physical findings
-Purpose of the physical exam
rule out medical reasons for symptoms
reassure pt that medical illness is unlikely
men
Depression - Diagnostics
Symptoms lead diagnostic choices
Depression screens
-Consider CBC, ESR, CMP, TSH
-EKG
-Atrial fibrillation, heart block
-MRI - Neurologic findings, psychotic sx, head trauma, depends on symptoms if need an MRI
-Toxicology screen
Depression - Management and Referral
Antidepressants - 1st line SSRI (takes 6 weeks to be effective)
Psychotherapy
Exercise - Very effective
Treat underlying causes
Refer for bipolar, antipsychotics, severe cases
Suicidal ideation indicates need for referral and actual suicidal plan is medic
Depression - Dysthymic Disorder
-Chronic form of LOW LEVEL Depression (at least 2 years) with fewer symptoms than MDD
-During most days the patient has two or more of the following symptoms:
-Change in appetite
-Insomnia or hypersomnia
-Fatigue or low energy
-Poor self-image
-Reduced co
Depression - Key Points
Depression is a primary mood disorder characterized by depressed mood and or decreased interest in things that used to give pleasure (anhedonia) during the same two week period, and representing a change from previous functioning
It Is a chronic and relap
Depression - DSM V Major Depressive Disorder (MDD)
A: Five or more of the following symptoms have been present during the same two week period and represent a change in function
At least one of the symptoms is either (1) depressed mood or (2) loss of interest (do not include symptoms that can be explained
Generalized Anxiety Disorder (GAD) - Epidemiology
12-month prevalence rate: 3.1%
Lifetime prevalence rate: 5.7%
Onset can occur any time in life, from adolescence to adulthood.
Predominant age: 45-49, lowest > 60
Predominant sex: Female > Male (2:1)
Common to be a co-morbidity with depression
GAD - Risk Factors
Female
Caucasian race
Adverse life events, including medical illness, disability, and unemployment
Family history
Lack of social support
Increase in stress
Depression
GAD - Manifestations of Anxiety
Generalized anxiety
Panic disorder-not a stand alone diagnosis-an abrupt surge of intense fear or discomfort that reaches a peak within minutes and contains at least four of the following:
Palpitations, sweating, trembling, SOA, choking, chest pain, nause
GAD - DSM V
-Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months about a number of events or activities (such as work or school)
-The individual finds it difficult to control the worry
-The anxiety and worry are
GAD - Somatic Symptoms
-Generalized-fatigue, insomnia, diaphoresis
-Neuro- dizziness, restlesness, paresthesias
-Cardiac-chest pain, palpitations
-Respiratory-hyperventilation, dyspnea
-GI-diarrhea, dry mouth, N & V
-Urinary-urgency, frequency
GAD - Subjective Data
-Symptoms are usually physical, general and nonspecific
-Unable to identify a specific area of concern
-May be able to identify a life trigger but most likely will state they have always been worriers
-Inquire about how this affecting their life
-Inquire
GAD - Objective Data
Physical exam is decided based on symptoms but needs to be inclusive
Perform comprehensive exam to help the patient understand it is anxiety and rule out other diagnosis
Possible Medical causes of anxiety
-Cardiovascular
-Dietary
-Drugs
-Hematologic
-Meta
GAD - Differential Diagnosis
Other Psychiatric disorders
CV
Respiratory
CNS
Metabolic
Nutritional
Medication and/or substances
GAD - Diagnostics
Anxiety scales
GAD-2 Over the past 2 weeks, how often have you been bothered by the following problems (1) feeling nervous, anxious or on edge (2) being unable to stop or control worrying (simple and quick, can perform and if positive then move on to one
GAD - Management and Referral
Psychotherapy
Antidepressants - SSRI or SRNI (more expensive), stay away from benzodiazepines (increase depression, addictive)
May use beta blocker or antihistamine for short-term until SSRI kicks in (Paxil and zoloft work well for anxiety)
Psychotherapy/
Bipolar Disorder - Pathophysiology
Dysregulation of biogenic amines or neurotransmitters (particularly serotonin, norepinepherine and dopamine)
MRI findings suggest abnormalities in prefrontal cortical areas, striatum and amygdala that predate onset of illness
A lot of research being done
Bipolar Disorder - Epdiemiology
Age
-Peak onset is 15 to 19 yrs, followed by the 20 to 24 yr range, 90% by age 30
-A late onset form peaks after age 60
Gender
-Affects both sexes equally but females are more at risk for rapid cycling (four or more mood episodes in one year)
-In children
Bipolar Disorder - Differential Diagnosis
Depends on presentation
Unipolar depression + psychotic features
Schizophrenia
Schizoaffective disorder
Personality disorders
Attention-deficit disorder + hyperactivity
Substance-induced mood disorder
Epilepsy (e.g., temporal lobe)
Brain tumor, stroke, de
Bipolar Disorder - DSM-V Bipolar I Disorder
For diagnosis of bipolar I-use the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes
A: A distinct period of abnormally and persistently elevated, expansive or
Bipolar Disorder - DSM-V Bipolar II Disorder
For diagnosis of bipolar II-use the following criteria for a hypomanic episode. The hypomanic episode may have been preceded by and may be followed by hypomanic or major depressive episodes
A: A distinct period of abnormally and persistently elevated, exp
Bipolar Disorder - DSM-V Cyclothymic Disorder
For at least 2 years there have ben numerous periods of hypomanic symptoms that do not meet the criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode
During the 2 year p
BD I vs BD II
BD I - Mania is 7 days or greater and patient can not function in normal day to day stuff
BD II - Mania is 4 days or more and patient can function in normal day to day stuff
Bipolar Disorder - Subjective Data
Do you have mood swings
Do you have problems sleeping
How is your appetite
Have you thought of harming yourself
Do you have any physical problems
Do you feel that people are against you
What are your main supports
If close relative or friend is present-ga
Bipolar Disorder - Objective Data
General appearance: Bright clothing, excessive makeup, disorganized or discombobulated, psychomotor agitation
Speech: Pressured
Mood/affect: Euphoria, irritability/expansive, labile
Thought process: Flight of ideas (streams of thought occur to patient at
Bipolar Disorder - Diagnostics
-TSH, CBC, CMP, ANA, RPR, HIV & ESR
-Drug/Alcohol Screen
-Mood Disorder Screen
-Consider brain imaging (CT scan, MRI) with initial onset of mania to rule out organic cause (e.g., tumor, infection, or stroke), especially with onset in elderly and if psycho
Bipolar Disorder - Management
Referral recommended-whether immediate-depends on comfort level of NP and stability of patient
At a minimum-know most commonly utilized Medications,
Rule out Bipolar before starting treatment for depression
Most bipolar patients will come in during their
Bipolar Pearls
-Patients come to see you when they are distressed, not when they are manic or hypomanic so if you do not consider this differential you may miss this
-BPD II is misdiagnosed frequently- 30% misdiagnosed with MDD
-BPD II is present for 13 years (on averag
Adult ADD/ADHD
In children male to female ratio is 4:1 in adults it is 1:1
Incidence is 3 to 6% in adults in ages 18 - 44
Pathophysiology
Genetics
Pre-frontal cortex
Dopamine, Noradrenergic
Nutritional deficits
Environmental toxins
Adult ADD/ADHD - Diagnosis
DSM-V: A persistent pattern of inattention and/or hyperactivity that interferes with functioning or development characterized by 6 or more inattention criteria and/or 6 or more hyperactivity/impulsivity criteria that has persisted for at least 6 months (a
Adult ADD/ADHD - Inattention Criteria
Careless mistakes in tasks
Difficulty in sustaining attention
Does not seem to listen
Does not follow through or finish tasks
Difficulty in organizing tasks
Avoids tasks that require sustained mental effort
Loses things
Easily distracted
Forgetful
Adult ADD/ADHD - Hyperactivity/Impulsivity Criteria
Fidgets
Difficulty in remaining seated
Runs or climbs excessively
Difficulty in playing quietly
Acts as if "driven by a motor"
Talks excessively
Blurts out answers before question is complete
Has difficulty in awaiting turn
Interrupts others
Adult ADD/ADHD - Subjective Data
Behavior rating scales
The adults ADHD self report scale (ASRS)
Barkley Adult ADHD rating scale
Wender Utah Rating Scale
Adult ADD/ADHD - Objective Data
Personal or strong family cardiac history may need a EKG or cardiology referral before starting stimulants
Rating Scales
Adult ADD/ADHD - Differential Diagnosis
Common co-morbid mental health issues
Diversion
Adult ADD/ADHD - Treatment
Multimodal treatments are most effective
Pharmacological treatment usually involves stimulants
Substance Abuse
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Eating Disorders
3 types according to DSM V
Anorexia Nervosa
Bulimia Nervosa
Binge eating or compulsive overeating
Anorexia
BMI < 17.5% - Cachexia, underweight
2 types of Anorexia
Restrictive - Restrict intake, exercise excessively
Binge eating/purging - restrict intake but have episodes of binging then purging
Diagnosing
Refusal to maintain appropriate body weight for age and
Bulimia
Normal to higher than normal body weight
2 types of bulimia
Purging - binge eating than purging
Nonpurging - binge eating than excessive exercise/fasting
Diagnosing
Episodes of binge eating (eating more than normal in one meal, feeling of not being able t
Compulsive overeating
Becomes Overweight
Binge eating without purging or excercise
Diagnosing
Binge eating episodes
Lack of control while eating
Binge eating occurs at least 1/week for 3 months
Not associated with purging, laxative use
3 or more symptoms present with binge eat
Eating disorders - Treatment
Medical stabilization
Nutritional therapy
Pharmacotherapy (SSRI, Trazadone)
Psychosocial therapy (cognitive behavior therapy)
Intimate Partner Violence (IPV)
Can be former, current or potential partner
Can be physical, mental or sexual
IPV - Incidence
Can affect all ages, genders and socioeconomic status
Accounts for 74% of all murder-suicides
IPV - Effects of IPV
Physical
IBS, physical welts/bruises
Sexual
Exposed to STDs, have pre-term labor, miscarriage
Psychological
Depression, alcohol abuse, substance abuse, eating disorders and phobios
IPV - NPs role
Screen
Support
Safety
Options for patient
Document everything
Barriers to screening
Practitioner
Do not know how to help
Do not want to offend
Do not have time
Abused person
Fear of abuser finding out
Depressed
IPV - Screening
Incorporate into routine questioning
People often will not volunteer if they are abused but will tell if questioned
Screening tools available
IPV - Intervention
Speak to victims
Be supportive
Conduct safety assessment
Is violence increasing
Threats to kill
Weapons in home
Provide options e.g. restraining orders
Validate strengths of abusee
Document everything, measure wounds/bruises and document word for word wha
IPV - Safety
-When violence occurs, move to a room with no weapons
-Have a code word for children to know when to go get help, teach children when and where to go
-Keep a "bug-out" bag with extra keys, cash and important documents with someone you trust
-Have children