DepressionPresenter: Robert R Edger MD Goals: How to identify it How to assess suicide potential What medications used to treat
depression Course of the illness This talk should give some ideas
about what questions you should ask your doctor about this illness.
What is Major Depression?
A complex interaction between multiple vulnerability genes and environmental factors
It is a chronic and recurrent illness and may be progressive, in that there may be structural changes in the brain at a cellular level e.g., changes in cortical thickness and neurodegeneration.
Associated with changes in endocrine function, immune function and autonomic function: e.g. obesity, hypertension, increase cholesterol, increased inflammation
Epidemiology
National Comorbidity Survey-Replication showed life time prevalence of 16.2%; 12 month prevalence 6.6%
Delay in treatment is on average 3 years
It is the leading cause of disability in the world according to WHO
Women: Men 2:1 Only about a quarter of people with
it ever get treated
Neurobiology
Stress and trauma, early and late life adversity for example child abuse, can result in the way genes function in the brain
Neurocircuitry controlling mood is effected: disconnect between cortical regulation and deeper structures in the brain
This leads to emotional dysregulation, cognitive impairment, behavioral symptoms, physical impairment and systemic manifestations like tiredness
Psychiatric Management of Depression
One of the best predictors of success in treating depression is establishing a good relationship with your doctor. If possible get family to come with you to give history
Tell the doctor if there were past treatment response, hospitalizations, suicide attempts
Was there any past abuse, trauma, substance use, medical conditions, sexual dysfunction, problems at work, and in relationships; problems in the military
Assessment
Family History: of mental illness, legal problems, substance abuse, suicide
Medical Conditions that may present as depression: thyroid disease, stroke, Parkinson’s disease, dementia, metabolic conditions, e.g. hypercalcemia, diabetes; malignancy, infections.
Medications that induce depression: anti-rejection agents, chemotherapy agents, interferon, steroids, antibiotics, accutane
Assessment
Is there Psychosis, Bipolar mood swings, mixed mania, switch to mania secondary to antidepressants (20% risk)
Psychosis is where there are hallucinations, paranoia, judgment and insight are gone
Bipolar Disorder is characterized by mood swings: highs and lows
Screening tools: Patient Health Questionnaire-9 (PHQ-9)
Suicide Assessment
We may hide suicidal/homicidal ideation as it is such frightening territory
Try to get collateral information: family, friends; elicit their support in monitoring; assess whether there is intent, not just thoughts of suicide
Are there lethal means available: guns Be aware of potential for aggression and
homicide, especially in patients with history of violent behavior and in post partum depressions
Factors to Consider in Assessing Suicide Risk
Lifetime history, nature, seriousness, and number of previous attempts and aborted attempts
Presence of hopelessness, psychic pain, decreased self-esteem, narcissistic vulnerability. Presence of severe anxiety, panic attacks, agitation, impulsivity
Factors to Consider in Assessing Suicide Risk
Nature of cognition, such as loss of executive function, thought constriction (tunnel vision), polarized thinking, closed-mindedness, poor coping and problem-solving skills
Presence of psychotic symptoms, such as command hallucinations or poor reality testing
Presence of alcohol or other substance Recent psychiatric hospitalization
Older male adults highest risk; teens risk of copy cat suicidePresence of disabling medical illnessPresence of acute or chronic psychosocial stressors, actual or perceived interpersonal losses, financial difficulties or changes in socioeconomic status (retirement), family discord, domestic partner violence
Factors to Consider in Assessing Suicide Risk
Absence of psychosocial support, such as poor relationships with family, unemployment, living alone, unstable or poor therapeutic relationship, recent loss of a relationship
History of childhood traumas, particularly sexual and physical abuseFamily history of or recent exposure to suicide especially in teenagers, copy cat attemptsAbsence of protective factors, such as children in the home, sense of responsibility to family, pregnancy, life satisfaction, cultural beliefs, or religiosity
Factors to Consider in Assessing Suicide Risk
Enhance treatment Adherence
Explain: when and how often to take medicine Reminder systems: pill boxes, alarms Take medications for several weeks to get
benefit Take medication even after feeling better Consult with doctor before d/c of medication Tell your doctor about concerns and fears,
understanding of meds, correct misconceptions Explain what to do if problems arise Concerns about cost need to be discussed: use
generics, patient assistance programs
Education of Patient and Family
Depression is not a moral defect but a medical illness; the family may be convinced there is nothing wrong
Explain course of treatment: first side effects may occur, neurovegetative symptoms may remit, then mood improves
Identify stressors that may trigger relapse Encourage routines: sleep/wake cycle,
eating, exercise, decrease alcohol, caffeine, tobacco products
Pharmacotherapy
The range of possible treatments: psychotherapy, medications, Light Therapy, ECT, complementary and alternative medicationsThere are no replicable, robust findings to suggest one agent is superior to anotherNo psychotherapy has been shown robustly to be better than others; psychodynamic, interpersonal therapies may have more benefit
Antidepressant Medications They do differ in their potential to
cause side effects; if they are going to work it will be in the first 1-2 weeks
SSRI’s, SNRI’s Mirtazapine and Bupropion are optimal agents to try first; Bupropion also has an indication for smoking cessation
Selective Serotonin Reuptake Inhibitors (SSRI) Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Vilazodone (Viibryd) Dose depends on the individual; elderly
need lower doses; GI Side effects; sexual side effects most common; seizures; fall risk; Osteopenia; weight gain
NDRI Norepinephrine Dopamine Reuptake Inhibitors Bupropion (Wellbutrin) Beware in using it if you have a
seizure history Don’t use it with a history of bulimia Commonly used with other
antidepressants although no proof that it helps
Serotonin Norepinephrine Reuptake Inhibitors SNRI Venlafaxine (Effexor) Desvenlafaxine (Pristiq) Duloxetine (Cymbalta) Side effects may include elevated
blood pressure, headaches, sexual dysfunction, sleep disruption
Other Antidepressants
Serotonin Modulators: Nefazodone, Trazodone
Nefazodone: can rarely cause liver damage
Norepinephrine Serotonin Modulator: Mirtazapine
Mirtazapine (Remeron) can stimulate appetite and be useful in cancer treatment; it can raise cholesterol and be sedating; can be a good add on medication; helps with sleep
Tricyclic Antidepressants
Amitriptyline, Doxepin, Imipramine, Desipramine, Nortriptyline
Many side effects: cognitive impairment, narrow angle glaucoma, delirium, fall risk, urinary retention, cardiac arrhythmia, orthostatic hypotension, constipation, dry mouth, seizures, sedation, sexual dysfunction, can be lethal in overdoses
Monoamine Oxidase Inhibitors (MAOI),Folic Acid, Omega3 Phenelzine, Tranylcypromine,
Isocarboxazid Selegeline (Emsam) Patch Dietary restriction: no aged cheese
or meats; red wine, draft beer, fava or broad beans
Risk of hypertension and stroke L-Methylfolate (Deplin) Omega 3 use between 1000-2000
mg daily
Response to Treatment
Remission is the goal: at least 3 weeks without sad mood or reduced interests and no more than 3 symptoms of depression remaining.
This only occurs in about 40-45% of patients in the best of hands
Residual symptoms predict recurrence. If you don’t respond in 2 weeks to a
medication, consider adding medication, or augmentation
Augmentation
Lithium: most studied adjunct. Useful in suicide prevention. Blood level of Lithium to attain has not been confirmed. Use at night as there is less risk to renal side effects.
Thyroid supplementation: triiodothyronine 25-50 mcg/day.
Augmentation: Atypical Antipsychotics
May increase the rate of response or remission to people who haven’t responded to 2 or more antidepressant trials, even if psychotic symptoms are not present
Use lower doses: Olanzapine: (Zyprexa); Aripiprazole
(Abilify); Quetiapine (Seroquel); metabolic side effects limit utility (weight gain, diabetes)
Augmentation
Stimulants: methylphenidate (Ritalin)or Dextroamphetamine (Adderall)
Modafinil (Provigil) and Nuvigil: may help with fatigue or hypersomnolence (caution when using with Oral Contraceptives)
Anticonvulsants: carbamazepine (Tegretol), valproic acid (Depakote), Lamotrigine (Lamictal).
Continuation Phase
Treat at least 4-9 months to prevent relapse assuming good control of depression
The risk of relapse is highest in the first 6 months after remission
Use same dosing as during the acute phase Monitor for contributors to relapse:
substance use, general medical conditions, psychosocial stressors, decrease adherence to medications
Maintenance Phase
Within the first 6 months following recovery from a major depression, 20% of patients will experience a recurrence.
Between 50-85% of patients will have a life time recurrence usually within 2-3 years
The risk of subsequent recurrences increases by 16% with each successive episode.
Patients with prior episodes of depression are at risk for mania, hypomania, dysthymia or chronic low grade depression
Maintenance Phase
People who have had 3 episodes of Major Depression-need medication indefinitely
Patients with risk factors: residual symptoms, ongoing psychosocial stressors, family history of mood disorder, the severity of prior episodes
Presence of psychosis in prior episodes and suicidal risk
In general the same medications and dose should be used as in acute and continuation phases
Relapse and recurrence of symptoms can still recur in up to 25% of patients
Discontinuation
Treatment can be discontinued if maintenance is not indicated.
The highest rate of relapse is 2 months after discontinuation of medications. Close monitoring should be done in this period.
Always taper and be aware of discontinuation symptoms, which may mimic depressive symptoms: disturbance of mood, energy, sleep and appetite
