Depression Jimmie D. McAdams, D.O.

SYMPTOMS OF DEPRESSION DEPRESSED MOOD MOST OF THE DAY, NEARLY EVERY DAY MARKED DIMINISHED INTEREST OR PLEASURE IN ALMOST ALL CUSTOMARY ACTIVITIES WEIGHT LOSS OR GAIN TOO MUCH SLEEP TOO LITTLE SLEEP

SYMPTOMS OF DEPRESSION EITHER MARKEDLY SLOW OR AGITATED MOVEMENTS LOSS OF ENERGY POOR CONCENTRATION SUICIDAL THOUGHTS/ATTEMPTS HOPELESS/HELPLESS WORTHLESS

GERIATRIC SYMPTOMS COGNITIVE IMPAIRMENT APATHY AND SOCIAL WITHDRAWAL FOCUS ON PAIN AND OTHER PHYSICAL COMPLAINTS LITTLE OR NO SADNESS DISPLAYED OR ADMITTED NEW ONSET ANXIETY

RISK FACTORS POOR PHYSICAL HEALTH GENETICS PRIOR DEPRESSIONS POOR SOCIAL SUPPORT/LOSSES POLYPHARMACY AGE RELATED CHANGES IN NEUROTRANSMITER AND HORMONE METABOLISM AND FUNCTION

PHYSICAL EXAM NEUROLOGIC EXAM LABORATORY TESTS EEG SLEEP STUDY DIAGNOSTIC IMAGING

Economic Burden of Depression Total Costs = $83.1 Billion Per Year* Absenteeism 43.6% Inpatient Care 10.7% Outpatient Care/ Partial Care 8.2% Pharmaceutical Costs 12.5% Death From Suicide 6.6% Decreased Productive Capacity 18.4% *2000 dollars Greenberg PE, et al. J Clin Psychiatry. 2003;64:

DEPRESSION KILLS DEPRESSED SMOKERS 40% LESS LIKELY TO QUIT LESS LIKELY TO ADHERE TO DAILY LOW DOSE ASPIRIN DOSE IN CORNARY ARTERY DISEASE PTS POST MYOCARDIAL INFARCTION PTS MORE LIKELY TO DROP OUT OF EXERCISE PROGRAMS INCREASES MORBIDITY IN MEDICAL ILLNESSES INCREASES MORTALITY IN POST MI PATIENTS, NURSING HOME PATIENTS, CANCER, CHF

SUICIDE 30,622 DEATHS TH LEADING CAUSE OF DEATH AGE RD LEADING CAUSE OF DEATH AGE TH LEADING CAUSE OF DEATH AGE PEOPLE PER DAY COMMIT SUICIDE 132,353 HOSPITALIZED FOLLOWING ATTEMPTS, 116,639 TREATED & RELEASED 2:3 HOMOCIDES:SUICIDES

SUICIDE 19% OF SUICIDES ARE 65+ HIGHEST IN ELDERLY WHITE MALES GUNS LOWEST IN ELDERLY BLACK FEMALES

SUICIDE DO YOU FEEL LIKE A BURDEN FEEL YOURSELF OR OTHERS MAY BE BETTER OFF IF YOU WERE DEAD THOUGHT ABOUT TAKING YOUR LIFE METHOD, MEANS, INTENT TRIED TO HURT SELF TAKING NEW RISKS

Clinical Stages in the Treatment of Depression Severity Normal mood Symptoms Depression Progression to disorder Relapse Response Remission Recurrence Relapse 50% improvement + + Recovery Acute ContinuationMaintenance Kupfer DJ. J Clin Psychiatry. 1991;52(Suppl):28–34. Copyright 1991, Physicians Postgraduate Press. Adapted/Reprinted by permission.

DIFFERENTIAL MAJOR DEPRESSION DYSTHYMIA BIPOLAR, I &II DEPRESSED PSYCHOTIC DEPRESSION ADJUSTMENT DISORDER DEPRESSION D/T MEDICAL COND. DEPRESSION D/T SUBSTANCE

MEDICATIONS ANALGESICS ESP. NARCOTICS STEROIDS SEDATIVE / HYPNOTICS ANTINEOPLASTICS INTERFERON

Anxiety Disorders 24.9% (lifetime prevalence) Major Depressive Disorder 16.2% (lifetime prevalence) Up to 60% Overlap Anxiety-Depression Comorbidity Brown TA, et al. J Abnorm Psychol. 2001;36: Kessler RC, et al. JAMA. 2003;289: Kessler RC, et al. Arch Gen Psychiatry. 1994;51:8-19. The lifetime prevalence of depression is 60% in patients with social anxiety disorder The lifetime prevalence of depression is 57% in patients with panic disorder

ANXIETY DISORDERS PANIC DISORDER AGOROPHOBIA PANIC DISORDER WITH AGOROPHOBIA SOCIAL ANXIETY DISORDER SPECIFIC PHOBIA OBSESSIVE COMPULSIVE DISORDER POST TRAUMATIC STRESS DISORDER GENERALIZED ANXIETY DISORDER

APA Treatment Guidelines Acute phase (Months 1–2) –Goal: achieve remission –Restore baseline level of symtomatology and functioning Continuation phase (Months 2–6+) –Goal: prevent relapse of episode –Medication dose that achieved remission should generally be used in this phase Maintenance phase (Months 6+) –Goal: prevent recurrence of new episode –Decision to employ maintenance treatment based on clinical condition of patient (eg, number and severity of prior episodes) American Psychiatric Association (APA) Practice Guidelines. Am J Psychiatry. 2000;157(Suppl):1–45.

TREATMENT ALL DEPRESSION SHOULD BE TREATED

TREATMENT OPTIONS PSYCHOTHERAPY PHARMACOTHERAPY ELECTROCONVULSIVE THERAPY (ECT)

TREATMENT TCA’S MOAI’S SSRI’S COMBINATION AGENTS MOOD STABILIZERS ATYPICAL ANTIPSYCHOTICS AUGMENTATION

TCA’S ANTIDEPRESSANT EFFECT WELL STUDIED GENERICS AVAILABLE NO ABUSE POTENTIAL EFFECTIVE DELAYED ONSET ANTICHOLINERGIC SIDE EFFECTS POSTURAL HYPOTENSION WEIGHT GAIN INITIAL STIMULATION FATAL IN OVERDOSE

MOAI’S ANTIDEPRESSANT EFFECTS NO ABUSE POTENTIAL EFFECTIVE WELL STUDIED NO OVER STIMULATION DIETARY RESTRICTIONS DRUG INTERACTIONS DELAYED ONSET INSOMNIA POSTURAL HYPOTENSION WEIGHT GAIN SEXUAL SIDE EFFECTS DANGEROUS IN OVERDOSE

SSRI’S EFFECTIVE BENIGN SIDE EFFECT PROFILE SAFETY NO ABUSE POTENTIAL ONCE A DAY DOSING DELAYED ONSET OF ACTION EARLY ANXIOGENIC EFFECT SEXUAL SIDE EFFECTS DOSE TITRATIONS DYSCONTINUATION

COMBINATION AGENTS EFFEXOR (VENLAFAXINE) SERZONE WELLBUTRIN REMERON CYMBALTA

MOOD STABILIZERS LAMICTAL DEPAKOTE LITHIUM

ATYPICALS ABILIFY ZYPREXA GEODON RISPERDAL INVEGA SEROQUEL

AUGMENTATION CYTOMEL (T3) PSYCHOSTIMULANTS LITHIUM ATYPICALS

ELECTROCONVULSIVE THERAPY MOST EFFECTIVE FORM OF TRX TRX OF CHOICE FOR: PSYCHOTIC DEPRESSION SUICIDAL DEPRESSION REFUSAL TO EAT/DRINK USED AFTER TRX FAILURES MULTIPLE MEDICATION TRIALS AUGMENTATIONS/COMBINATIONS

PSYCHOTHERAPY COGNITIVE-BEHAVIORAL CHANGE BEHAVIOR AND MODES OF THINKING ACTIVITY SCHEDULE PLEASURE LOGS EXAMINING DISTORTIONS eg.OVERGENERALIZATIONS, CATASTROPHIZING, DICHOTOMOUS THINKING GENERATE NEW WAYS TO VIEW ONE’S LIFE CHALLENGE WORTHLESS, HELPLESS, HOPELESS SUPPORTIVE