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Depressive Disorders by

Depressive Disorders

50% of depression cases are under-­dia­gnosed and untreated
Of 200 people in the community
40 will present to family physician
20 have psycho­logical symptoms
10 will be correctly diagnosed
1 will be adequately treated with anti-d­epr­essants

Substa­nce­-in­duced Depressive Disorder

Symptoms directly r/t physio­logical effect of substance
Associated with withdrawal or intoxi­cation of substance
Alcohol, amphet­amines, cocaine, halluc­ino­gens, opioids, sedatives, anxiol­ytics

MDD with psychotic Features

Depressed but also experi­ences delusions and halluc­ina­tions
Mood congruent - put client at serious risk for self-h­arm­/su­icide
Moon incong­ruent - hears voices disagr­eeing with their current beliefs regarding self-e­steem
ECT treatment of choice

MDD - Peripartum onset

50% post partum depression begins prior to delivery
may occur up to 1 year post-d­elivery
Predictor for bipolar disorder in later years
Etiology
Combination of hormonal, metabolic and psycho­social influences
Treatment is based on severity
4-25% developing post-p­artum depression in fathers

Tricyclic Antide­pre­ssants

Inhibits re-uptake of norepi­nep­hrine and serotonin
Elevates levels of neurot­ran­smi­tters therefore elevating mood
May cause sedation
Antich­oli­nergic effects (Dry mouth, blurred vision, N&V, consti­pation)
Amitry­pty­line, Desipr­amine, Nortri­pty­line, Imipramine
May take up to 8 weeks to be effective
Take as directed, usually at hs

Monoamine Oxidase Inhibitors (MAOI)

Cannot ingest tyramines as it may lead to hypert­ension crisis
Cheese, liver, wines, most dairy, bananas, soy sauce, beer, avocados
Watch use of over-t­he-­counter drugs
Ie.
Phenelzine (Nardil), Tranyl­cyp­romine (parnate), isocar­boxazid (marplan)
 

Epidem­iology of Depression

Higher in females than males (2:1)
Women experience depression from age 10-midlife
Age 44-65 gender difference is less pronounced
65+ y/o have higher tendency to be depressed

Predis­posing Factors

Genetics
Monozygotic twins: 37% MDD
common amongst first degree relatives
Bioc­hemical Factors
Deficiency in neurot­ran­smi­tters (Norep­ine­phrine, serotonin, dopamine and Acetylcholine)
Serotonin plays important role in mood/a­nxi­ety­/ar­ous­al/etc.
Elec­trolyte disturbances
Excessive sodium bicarb­ona­te/­calcium levels
Excess potassium
Hormonal Disturbances
Dysfunction in adrenal cortex
Depression associated with hyperthyroidism
Imbalance of estrogen and proges­terone
Nutr­itional Deficiencies
Vitamin B, Vitamin C, iron, folic acid, zinc, calcium, potassium
Glucose intole­rance fluctu­ations, abnormal fatty acids

MDD - Atypical Features

Different presen­tation of Symptoms
Mood reacti­vity, weight gain, hypers­omnia, leaden paralysis, etc.
Interv­ention with anti-d­epr­essants may worsen symptoms
Treated with mood stabilizers
Lithium, lamotr­igine, carbam­azepine

Selective Serotonin Reuptake Inhibitors (SSRIs)

Blocks neural uptake of serotonin which increases levels of serotonin available
Increases serotonin therefore elevating moods
Fewest adverse and cardio­toxic effects
Decreases libido, agitation, insomnia, weight loss, seizures, increase suicidal ideation
Fluoxitine (prozac), paroxetine (paxil), Citalopram (Celexa), Sertraline (zoloft), and venlaf­axine (Effexor)

Other Antide­pre­ssants

Norepi­nep­hrine dopamine re-uptake inhibitor
Wellbutrin (bupro­pion)
Serotonin norepi­nep­hrine Disinhibitor
Remeron (mirta­zapine)
Alter neurot­ran­smi­tters in the brain
 

Persistent Depressive Disorder Dysthymia

Similar to MDD, but milder
Chroni­cally depressed for most of day, more days than not for at least 2 years

Premen­strual Dysphoric Disorder

Depressed mood
Excessive anxiety
mood swings
decreased interest in activities
Occurs week prior to menstr­uation
Becomes minimal or absent in well post menstr­uation

Clinical Aid Dx Depression

S
Sleep distur­bances
A
Appetite changes
D
Dysphoria
A
Anhedonia
F
Fatigue
A
Agitation
C
Concen­tration
E
Esteem
S
Suicide

MDD - With Anxious Distress

Meets criteria for MDD but experi­ences anxiety symptoms
Anxiety usually present in depression

Treatment of Depression

Phar­mac­oth­erapy
Psychotherapy
Cognitive Behavi­oural Therapy
Interpersonal Therapy
ECT
Develops quick response
Group Therapy
WOrks better after recovery has begun

Serotonin Syndrome

Assess if pt is on high doses of SSRIs
Signs and Symptoms
Change in mental status
Diaphoresis
Lethargy
Abdominal pain
Myoclonus/tremors specific for serotonin syndrome
Hyperthermia & tachycardia
apnea
Discon­tinue SSRIs immedi­ately

Benzod­iaz­epines

Used to treat anxiety and anxiety disorders
Potent­iates the action of GABA - major calming neurot­ran­smitter in the CNS
Diazepam (valium), Alprazolam (xanax), lorazepam (ativan)
Decreases anxiety while antide­pre­ssant takes effect
Should be decreased and stopped once antide­pre­ssant becomes effective

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