Depression-Assessment
B. Anthony Lindsey, MD
Professor and Vice Chair
UNC Department of Psychiatry

Pgy2 level-not what can be learned from a book or an article/overlap with Brad/Big picture/ talking about treatment of major depression

SCOPE OF THE PROBLEM

The Global Burden of Disease Study reported unipolar depression as the fourth leading cause of disability in the world.Projections for 2020 suggest that unipolar major depression will be the second leading cause of disability worldwide.

EpisodeDisorder

*Major depression episode*Major depression disorder

*Major depression episode+ *Bipolar disorder, Type I

manic/mixed episode

*Manic/mixed episode *Bipolar disorder, Type I

*Major depressive episode+ *Bipolar disorder, Type II

hypomanic episode

*Chronic subsyndromal *Dysthymic Disorder

depression

*Chronic fluctuations

between subsyndromal *Cyclothymic disorder

depression & hypomania

If I had __________, Id be depressed too.

Definitions

Mood - a persons sustained emotional state

Affect the outward manifestation of a persons feelings, tone, or mood

Major Depression

Syndromal classification with disturbances of mood, neurovegetative and cognitive functioning

Major Depression

At least 5 of the following symptoms present for at least 2 weeks (either #1 or #2 must be present):

1) depressed mood

2) anhedonia loss of interest or pleasure

3) change in appetite

4) sleep disturbance

Major Depression

5) psychomotor retardation or agitation

6) decreased energy

7) feeling of worthlessness or inappropriate guilt

8) diminished ability to think or concentrate

9) recurrent thoughts of death or suicidal ideation

Major Depression

Symptoms cause marked distress and/or

impairment in social or occupational functioning.

No evidence of medical or substance-induced etiology for the patients symptoms.

Symptoms are not due to a normal reaction to the death of a loved one.

Bereavement and
Late Life Depression

25 35% of widows/widowers meet diagnostic criteria for major depressive disorder at 2 months.

~15% of widows/widowers meet diagnostic criteria for major depressive disorder at one year.

This figure remains stable throughout the second year.

Subtypes of Depression

Atypical

Reverse neurovegetative symptoms

Mood reactivity

Hypersensitivity to rejection

MAO-Is and SSRIs are more effective treatments

Subtypes of Depression

Psychotic (~10% of all MDD)

Delusions common, may have hallucinations

Delusions usually mood congruent

Combined antidepressant and antipsychotic therapy or ECT is necessary

Subtypes of Depression

Melancholic

No mood reactivity

Anhedonia

Prominent neurovegetative disturbance

More likely to respond to biological treatments

Subtypes of Depression

Seasonal

Onset in Fall, remission in Spring

Hypersomnia is typical

Less responsive to medications

A.M. light therapy (>2,500 lux) is effective

Subtypes of Depression

Catatonic

Motoric immobility (catalepsy)

Mutism

Ecolalia or echopraxia

Epidemiology

Point prevalence

6 8% in women3 4% in men

Lifetime prevalence

20% in women10% in men

Epidemiology

Age of Onset

Throughout the life cycle, typically from the mid 20s through the 50s with a peak age of onset in the mid 30s

Epidemiology

Genetics

More prevalent in first degree relatives

3-5x the general population risk

Concordance is greater in monozygotic (~50%) than dizygotic (~15%) twinsIncreased prevalence of alcohol dependence in relatives

Etiology

Original, clearly over simplistic theories regarding norepinephrine and serotonin

Deficiency states depression

States of excess mania

Problems with initial theories

Inconsistent findings when studying measures of these systems: MHPG (3 methoxy 4 hydroxyphenolglycol) and 5HIAA (5 hydroxy indoleacetic acid) in the urine and CSF.Treatments block monoamine uptake acutely, however the positive effects occur in 2-4 weeks.

Receptor theory more useful

Antidepressant treatment causes a down regulation in central adrenergic (beta) and serotonergic (5HT2) receptors

This change corresponds temporally to the antidepressant response

Serotonin and Depression

Decreased CSF levels of serotonin metabolites Decreased serotonin transporter bindingAcute tryptophan depletion can cause worsening in patients previously responsive to SSRIs

Gene-Environment Interactions

Individuals who have one allele for a low efficiency serotonin transporter are more vulnerable to depression after experiencing environmental stressors (Kendler 2005, Caspi 2003, Lenze 2005)

Neuroendocrine

Hyperactivity of HPA axis:

Elevated cortisol

Nonsuppression of cortisol following dexamethasone

Hypersecretion of CRF

Blunting of TSH response to TRHBlunting of serotonin mediated increase in plasma prolactinBlunting of the expected increase in plasma growth hormone response to alpha-2 agonists

Functional Neuroimaging (PET,SPECT)

Dorsal prefrontal cortex

Anterolateral (concentration, cognitive processing)

Anterior cingulate (regulation of mood and affect)

Subcortical

Caudate (psychomotor changes)

Decreased metabolic activity

Increased metabolic activity

Ventral prefrontal cortex

Psychosocial

Risk Factors

Poor social supports

Early parental loss

Early life trauma

Female gender

Chronic medical illness

Introversion

Psychosocial

Cognitive Theory

Patients have distorted perceptions and thoughts of themselves, the world around them and the future

Possible to treat by restructuring

Secondary Causes of Depression

ToxicEndocrineVascularNeurologicNutritionalNeoplasticTraumaticInfectiousAutoimmune

Depression Differential Diagnosis

Adjustment Disorder with depressed mood

Maladaptive and excessive response to stress, difficulty functioning, need support not medicines, resolve as stress resolves

Dysthymic Disorder

Bipolar Disorder

Other Psychotic Disorders if psychotic subtype

Personality Disorders (cluster B) Mood instability with rapid changes is characteristic

Treatment

Biologic

Tricyclic antidepressantsMonoamine oxidase inhibitorsSecond generation antidepressants

SSRIs, Venlafaxine, duloxetine, bupropion, mirtazapine

Electoconvulsive therapy

Treatment

Psychosocial Treatments

EducationSpecific psychotherapiesVocational trainingExercise

Treatment

When to Refer?

Question regarding suicide riskPresence of psychotic symptomsPast history of maniaLack of response to adequate medication trial

Treatment

Course

One episode 50% chance of reoccurenceTwo episodes 70% chance of reoccurenceThree or more episodes - >90% chance of reoccurence

Dysthymic Disorder

Characteristics

Chronically depressed mood for most of the day, more days than not, for at least two years. Can be irritable mood in children and adolescents for 1 yearWhile depressed, presence of at least two of the following

Poor appetite or overeating

Sleep disturbance

Low energy or fatigue

Low self esteem

Poor concentration

Feelings of hopelessness

Dysthymic Disorder

Never without depressive symptoms for over 2 monthsNo evidence of an unequivocal Major Depressive Episode during the first two years of the disturbance (1 year in children and adolescents)No manic or hypomanic episodesNot superimposed on a chronic psychotic disorderNot due to the direct physiologic affects of a substance or a general medical condition

Epidemiology

More prevalent in women, 4% prevalence in women, 2% in menOnset is usually in childhood, adolescence or early adulthoodOften is a superimposed Major DepressionHigh prevalence of substance abuse in this group

Differential Diagnosis

Other mood disordersMood disorder due to a general medical condition

Treatment

If no superimposed Major Depression

Psychotherapy

Some evidence suggest responsiveness to antidepressant medication in some sub- groups

Course

Prognosis is not as good as Major Depression in terms of total symptomatic remission