1. Alex Padikken 4 th Year Pharmacy Student Florida A&M University Disease State presentation

2. Objective Define Depression Discuss the signs and symptoms Discuss risk factors, prevalence and pathophysiology Describe the components of diagnosis and treatment options.

3. Definition Depression is defined as intense feelings of sadness, mental slowing, hopelessness, despair, pessimistic worry, agitation, self- deprecation and inability to experience pleasure during usual activities.

4. Prevalence 6.7% of US adults experience major Depressive disorder each year. Women are 70% more likely than men to experience depression. Average age of onset is 32 years old. Non-Hispanic blacks are 40% less likely than Non-Hispanic whites to experience Depression.

5. Signs and Symptoms Fatigue Feeling of Hopelessness Feeling “empty” Irritability Restlessness Decreased energy Difficulty concentrating Appetite loss Insomnia Thoughts of suicide

6. Risk Factors Gender: Female Having biological relatives with Depression Abusing alcohol or any illicit drugs Having traumatic experiences as a child Depressed previously Having serious medical conditions such as Parkinson's disease, dementia, stroke, HIV/Aids.

7. Etiology The cause of depression are not well understood. Combination of genetic, biologic and environmental factors.

8. Pathophysiology Due to an alteration in neuronal and synaptic catecholamine concentration at adrenergic receptor sites in the brain, deficiency of catecholamine, especially NE and 5-HT

9. Depressed VS Not Depressed

10. Depression Diagnosis DSM IV – Diagnostic and statistical manual of mental disorder At least five symptoms from the following list during the same two week period – Depressed mood – Marked diminished interest – Significant weight loss or weight gain – Insomnia or hypersomnia – Psychomotor agitation or retardation – Fatigue or loss of energy – Feelings of worthlessness – Diminished ability to concentrate – Recurrent suicidal ideation

11. Types of Depression Major Depression Dysthymic Disorder Minor Depression Postpartum Depression Seasonal affective Depression

12. Major Depression Combination of symptoms interfering a person’s ability to: – Work – Sleep – Study – Eat – Pleasurable activities

13. Dysthymic Disorder Characterized by long term symptoms that prevents a person's normal functioning or well being. Minor Depression Characterized by having symptoms for 2 weeks or longer that do not meet full criteria for major depression.

14. Postpartum Depression This is a common type of depression that occurs in new mothers. It often occurs between two weeks and six months after delivery. Seasonal affective Depression (SAD) This type of depression is related to changes in seasons.

15. Non-Pharmacological Treatment St. John’s Wort – Not approved by FDA – Classified as a dietary supplement – Associated with many significant drug interactions Omega 3 fatty acids – Supplement may ease depression – Used in addition to other standard depression treatment.

16. Non-Pharmacological Treatment Psycotherapy – Cognitive-behavioral therapy (CBT) – Interpersonal therapy (IPT) Electroconvulsive Therapy – Formerly known as “shock” therapy.

17. Treatment Options SSRI – SSRIs block the reabsorption of the neurotransmitter serotonin in the brain – Most commonly prescribed antidepressants. – Ease symptoms of moderate to severe depression – Relatively safe and fewer side effects. Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Fluoxamine (luvox) SIDE EFFECTS: reduced sexual desire, weight gain or weight loss, N/V, GI issues.

18. Treatment Options SNRI – block the absorption of the neurotransmitters serotonin and norepinephrine in the brain. – Effective at easing depressive symptoms – Similar to SSRI Duloxetine (Cymbalta) Venlafaxine (Effexor XR) Desvenlafaxine (Pristiq) SIDE EFFECTS: N/V, Sexual dysfunction, dry mouth, also increase BP.

19. Treatment Options Tricyclics – Block the absorption of the neurotransmitters serotonin and norepinephrine – Block Ach and histamine receptors – Earliest antidepressants developed – Adjunctive analgesics for chronic pain conditions, such as trigeminal neuralgia – Childhood enuresis (imipramine) Amitriptyline (elavil) Desipramine (Norpramin) Doxepin (sinequan) Imipramine (Tofranil) Nortriptyline (Pamelor) Protriptyline (Vivactil) Trimipramine (Surmontil) SIDE EFFECTS: Dry mouth, blurred vision, urinary retention, constiption, weight gain, vivid dreams

20. Treatment Options MAO-Is – Inhibit MAO and cause accumulation of 5- HT, NE and DA in CNS and Periphery – Highly effective – Disadvantage: potential to cause hypertensive crisis when taken with tyramine – Use is limited due to dietary restrictions Isocarboxazid (Marplan) Phenelzine (Nardil) Selegiline (Emsam) Tranylcypromine (Parnate) SIDE EFFECTS: Dry mouth, headache, dizziness, drowsiness, insomnia

21. Additional Agents Bupropion (Wellbutrin) Mirtazapine (Remeron) Trazodone (Oleptro) Nefazodone DA and NE reuptake inhibitors NE and 5HT reuptake inhibitors Inhibits 5HT reuptake and alpha 1-adrenergic and histamine blocker Similar to Trazadone but less sedating and increased risk of hepatotoxicity

23. Special Population Pediatric Patients – Childhood depression is very common – Only FDA approved medication is Fluoxetine Elderly patiets – SSRIs are the first line therapy – Age 65 and older have the highest suicide rate

24. Clinical pearls All antidepressant comes with a black box warning Benefit of the medication start within 1-2 weeks It takes 6-8 weeks to see the full drug effect SSRIs and SNRIs are considered first line treatment options

25. Pharmacist Role Dispense Medication Guide and instruct patients to read it Counsel on lag time and the need to take it daily as with other agents Counsel the patients on side effects Counsel the patient to avoid abruptly discontinuing the antidepressants without consulting the physician.

26. References Mann JJ. The Medical Management of Depression. N Engl J Med 2005;353:1819– 1834. O'Connor EA, Whitlock EP, Beil TL, Gaynes BN. Screening for depression in adult patients in primary care settings: a systematic evidence review.Ann Intern Med. 2009 Dec 1;151(11):793-803. Association AP. Practice guideline for the treatment of patients with major depressive disorder (revision). American Psychiatric Association. Am J Psychiatry 2000; 157: 1-45. U.S. Preventive Services Task Force. Screening for depression in adults: U.S. preventive services task force recommendation statement. Ann Intern Med. 2009 Dec 1;151(11):784-92. Staff, Mayo Clinic. "Definition." Mayo Clinic. Mayo Foundation for Medical Education and Research, 10 Feb. 2012. Web. 02 Oct. 2013. Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta- analysis of randomized controlled trials.JAMA. 2007 Apr 18;297(15):1683-96.

27. QUESTIONS ???