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

2. 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).

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

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

11. 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

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

13. 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

14. 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.

15. Others Bupropion Mirtazapine Trazodone Stimulants D-amphetamine
Methylphenidate

16. 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

17. 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

18. Common Augmentation Medications
Lithium
Thyroid hormones

19. 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.

20. 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

21. 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

22. 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

23. 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

24. Additional resources for you and your patients
Crisis Text Line 24/7
Text “HOME” to
Live, trained counselors offering support and information via secure platform
National Suicide Prevention Lifeline
Benton & Franklin Counties Crisis Response Unit: (Tri-cities) or
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

25. 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

26. 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

27. 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

28. 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.

29. 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

30. 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

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

32. 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

33. SSRI for PTSD
Sertraline
Paroxetine
Fluoxetine

34. SNRI for PTSD
Venlafaxine

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

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

37. 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)

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

39. 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

40. Questions?