MDD & PTSD By: Farrukh Hashmi MD Board certified in Psychiatry and Neurology Lourdes Counseling Center Reliance Medical Center

Major depressive disorder Diagnosis Criteria According to DSM-V Diagnostic Code (F32.X and F33.X) Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure (Anhedonia).

Major depressive disorder Depressed mood most of the day Markedly diminished interest or pleasure in all/almost all activities Significant weight change not due to other medical condition Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Diminished ability to think or concentrate, or indecisiveness Recurrent thoughts of death, SI w/ past attempt or specific plan

Differential diagnosis of clinical depression Major Depressive Disorder (MDD) Bipolar Disorder Seasonal Affective Disorder (SAD) Psychotic Depression Peripartum (Postpartum) Depression Premenstrual Dysphoric Disorder (PMDD) “Situational” Depression—Significant Life Changes Dysthymia

Comorbidities of Depression Depressive and anxiety disorders commonly occur together in patients presenting in the primary care setting The presence of depressive/anxiety comorbidity substantially increases medical utilization Is associated with greater chronicity, slower recovery, increased rates of recurrence, and greater psychosocial disability Long-term treatment is indicated SSRI (Selective Serotonin Reuptake Inhibitor) is preferred

Route to treatment Appearance of Symptoms but Lack of Insight Life is not great but it goes on Recognition of Changes in Mood It’s caused by stress from work and family Self-Medication Alcohol, marijuana, and other illegal street drugs to enhance my mood Visit to My PCP Referral to a Specialist Gaining insight and judgement toward my illness Most patients resist of seeing a mental health specialist unless it is strongly recommended by their PCPs

Route to Treatment It is estimated that about 70% of visits to PCPs are psychosocial related issues Different patients presents themselves differently. Gender/ Race Only less than a quarter of those issues will be referred to a specialist PCPs are often the final stop for most patients with mild to moderate psychiatric conditions

If things aren’t bad enough already… Often time, there is also the issue of substance abuse The National Bureau of Economic Research reports that people who have been diagnosed with a mental illness at some point in life consume 69 percent of the nation’s alcohol and 84 percent of the national’s cocaine People who abuse substances are more likely to suffer from depression (substance induced depression) People who are depressed may drink or abuse drugs to lift their mood(self medicated)

Treatment for Depression First, rule out other medical conditions that may cause depression Medications Therapy sessions (CBT is the most common type, but also not limited to psychoanalysis, psychodynamic, interpersonal, etc.) Brain Stimulation Techniques—ECT and TMS

Medications for Depression SSRI—Selective Serotonin Reuptake Inhibitor SNRI—Serotonin and Norepinephrine Reuptake Inhibitor TCA—Tricyclic Antidepressant MAOI—Monoamine Oxidase Inhibitor Others—stimulant

SSRI Citalopram Escitalopram Paroxetine Fluoxetine Sertraline Vilazodone Vortioxetine Side Effects: Drowsiness Nausea Dry mouth Insomnia Diarrhea Nervousness, agitation or restlessness/ suicidal ideas Dizziness Sexual problems Blurred vision Headache / weight gain

SNRI Venlafaxine Side Effects: Desvenlafaxine Upset stomach Duloxetine Levomilnacipran Side Effects: Upset stomach Insomnia Sexual problems Anxiety Dizziness Fatigue Weight gain

TCA Amitriptyline Desipramine Doxepin Imipramine Nortriptyline Protriptyline Trimipramine Side Effects: Stomach upset Dizziness Dry mouth Changes in blood pressure, in blood sugar levels Nausea Weight gain Sexual side effects

MAOI Phenelzine Tranylcypromine Isocarboxazid Not very commonly prescribed due to severe interaction with other medications and food Foods that can negatively react with the MAOIs include aged cheese, aged meats , Alcohol.

Others Bupropion Mirtazapine Trazodone Stimulants D-amphetamine Methylphenidate

ECT Electroconvulsive therapy Gold standard for treating MDD when standard treatments have failed Major side effects include transient memory loss, along with nausea, headache, jaw pain or muscle ache Refer to a specialist if your patient is interested in trying out ECT

TMS Transcranial Magnetic Stimulation Therapy Less invasive than ECT, less side effects Suitable for patients who are planning to become pregnant Suitable for patients who are unable to tolerate side effects of most oral medications Refer to a specialist if your patients express interest in this kind of treatment

Common Augmentation Medications Lithium Thyroid hormones

Suicide risk evaluation Vague suicidal ideas. Actively thinking about committing suicide. Making plans, giving away prized possessions, writing note, good bye letter. Attempting suicide. Committing suicide.

Suicide risk evaluation (Cont.) Who attempts more? Who completes more and why? Suicide gesture vs. Lethality of attempt. Most risky patient in your clinic or ER. Understanding the risk factors and protective factors for suicidal attempt When to refer your patients to the Crisis Response Unit for inpatient admission/treatment

Know the warning signs Talking/thinking about wanting to die Looking for a way to end its own life Talking/thinking about feeling hopeless or having no reason to live Talking about feeling trapped or in unbearable pain Talking about being a burden to others Increasing the use of alcohol or drugs Acting anxious or agitated, behaving recklessly Sleeping too little or too much Withdrawing or isolating from society Showing rage or talking about seeking revenge Extreme mood swings

Depression/suicide rating scales Limitations and Pitfalls: Total score is not a valid diagnosis Unable to show dose-response relationship during treatment Extremely subjective Interpretation should be based on proper training

Depression/suicide rating scales Hamilton Depression Rating Scale (most common) Beck Scale for Suicide Ideation Major Depression Inventory Patient Health Questionnaire Suicide Risk vs. Protective Factors Worksheet GAIN-SS

Additional resources for you and your patients Crisis Text Line 24/7 Text “HOME” to 741741 Live, trained counselors offering support and information via secure platform National Suicide Prevention Lifeline 800-273-8255 Benton & Franklin Counties Crisis Response Unit: 509-783-0500 (Tri-cities) or 800- 783-0544 Call and request a Designated Crisis Responder for an evaluation In the mean time, refer your patients to the ER for crisis stabilization Never send your patient home alone if he/she expresses active suicidal thoughts/plans/intents

PTSD Used to be called Shell Shock, Battle Fatigue or Soldier's Heart Vietnam war, Afghanistan war, Iraq war, etc. However, PTSD is not exclusive to veterans or military personnel Common patients with PTSD also include victims of rape, DV and other traumas

Combat trauma vs. civilian trauma Soldiers with war-related events have multiple factors that may reduce the prevalence of PTSD: being mentally prepared for events having unit support at the time of the events receiving treatment upon returning from deployment Soldiers with war-related events have greater access to and utilization of mental health services, which in turn reduce the prevalence of certain PTSD symptoms

PTSD PTSD usually develops within 6 months of the traumatic event Once begun, PTSD is often a chronic disorder associated with significant disability and handicap, affecting relationships, work and physical health The speed of recovery being greater for individuals who have received professional treatment

PTSD – F43.10 Diagnosis Criteria According to DSM-V (MUST MEET ALL) Criteria A: Stressor (direct/indirect exposure) Criteria B: Intrusion symptoms (flashback, nightmare, upsetting memories) Criteria C: Avoidance (of trauma related stimuli) Criteria D: Negative Alterations in Cognitions and Mood (negative thoughts or feelings worsen after the exposure to trauma) Criteria E: Alteration in Arousal and Reactivity (aggression, destructive behavior) Symptoms last for more than 1 month, create distress or functional impairment, and are not due to medication or other illnesses.

Genetic Disposition of PTSD According to a study, 47% of the variance in low-risk trauma exposure and 60% of the variance in high-risk trauma exposure were attributable to additive genetic factors Heritable influences accounted for 46% of the variance in PTSD

Common Symptoms of PTSD Anxiety or fear of danger to self or loved ones Easily startled by loud noises or sudden movement Flashbacks of image from the traumatic event Tense muscles, trembling or shaking, nausea, headaches, sweating and tiredness Lack of interest in usual activities Sleep problems Guilt and self-doubt for not having acted in some other way during the event, or feeling responsible for the event

Treatment options Therapy sessions (CBT is the most common type, but also not limited to psychoanalysis, psychodynamic, interpersonal, etc.) Medications

Medications Medications that have been shown to be helpful in treating PTSD symptoms are some of the same medications also used for symptoms of depression and anxiety: SSRI SNRI Others

SSRI for PTSD Sertraline Paroxetine Fluoxetine

SNRI for PTSD Venlafaxine

Others Atypical antipsychotics (olanzapine, quetiapine, risperidone, lurasidone, paliperidone, aripiprazole) Anti-anxiety (hydroxyzine, benzodiazepines, trazodone) Mood stabilizers (lithium, carbamazepine, lamotrigine, valproate, asenapine)

PTSD rating scales Limitations and Pitfalls: Total score is not a valid diagnosis Extremely subjective Interpretation should be based on proper training

PTSD rating scales Davidson Trauma Scale--SPAN Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) PTSD Checklist for DSM-5 (PCL-5) Short Post-Traumatic Stress Disorder Rating Interview (SPRINT) Trauma Screening Questionnaire (TSQ)

Additional resources for you and your patients Love Is Respect Non-profit Organization—Certified counselors available 24/7 www.loveisrespect.org online one-on-one chat Or text “LOVEIS” to 22522 You can also call 866-331-9474 National Domestic Violence Hotline 800-799-SAFE (7233) Mental Health America 800-969-6MHA (6642) National Sexual Assault Hotline 800-656-HOPE (4673) Veteran Crisis Line 800-273-TALK (8255)

References DSM5 Diagnostic Criteria Major Depressive Disorder - Pearson Clinical Substance Abuse and Depression - Kathleen Smith LPC, PhD Common Heritable Contributions to Low-Risk Trauma, High-Risk Trauma, Posttraumatic Stress Disorder, and Major Depression - Carolyn E. Sartor, PhD PTSD: National Center for PTSD The differences between war- and civilian-related traumatic events and the presentation of posttraumatic stress disorder and suicidal ideation in a sample of National Guard soldiers - Marta R. Prescott

Questions?