Mood Disorders Mental Problems Related to Mood episodes
Mood Disorders
Mental Problems Related to Mood episodes l Mood Disorders l Specifiers l
Mood Sustained emotion that colors the way we view life. l Mood D/O’s seen in 20% of women and 10% of men* l 50% of typical mental health practice l
Male Risk Factors Isolation l Anhedonia l Limited Physical Activity l Limited Self-reflection l Denial/Pessimistic l
Mood Disorders l l l l Major Depressive Episode Dysthymic Depressive Disorder NOS Manic Episode Bipolar II Cyclothymic Bipolar Disorder NOS
Other Mood Disorders Mood Disorder due to GMC? l Substance-Induced Mood Disorder l Mood Disorder NOS l
Other causes of Depressive and Manic Symptoms Schizoaffective Disorder l Cognitive Disorders with depressed mood l Adjustment Disorder with Depressed Mood l Personality Disorders l Bereavement l
Specifiers With Atypical Features* l With Melancholic Features l With Catatonic Features l With Postpartum Onset l
Course of Recurrent Episodes With/without Full Interepisode Recovery l With Rapid Cycling l With Seasonal Pattern l
Major Depressive Episode Quality of depressed mood l Duration l Symptoms l Impairments l Exclusions l
Depressive Symptoms Depressed mood l Anhedonia l Lost appetite and weight l Insomnia l Psychomotor retardation l Agitation l Suicidal ideation l
Theories of Depression Cognitive (Beck) l Learning (Seligman) l Neuroendocrine l Circadian Rhythm Hypotheses l Neurotransmitter l
Cognitive Aspects of Depression Pessimism (underestimates likelihood of success) l Lack of Self-esteem (underestimate the value of past achievements) l “It doesn’t matter” (responses won’t make a difference) l Biased judgement (toward negativism) l
Neuroendocrine Abnormalities l l Hypercorticolism (dysfunction in HAP axis) Dexamethasone suppression test – – l l basis of test-diagnostic and treatment marker procedure Problems Utility? Blunting of plasma growth hormone Blunting of serotonin-mediated increase in plasma prolactin
Circadian Rhythm Abnormalities Patterns of insomnia and hypersomnia l Diurnal fluctuations in mood l Seasonal pattern depression (ultradian) l Abnormalities in sleep architecture l Impact of: l – antidepressants on sleep architecture – phototherapy – reset biological clocks (endogenous zeitgebers)
Medication: Placebo? l l Kirsh et al (1999) 80 % Placebo Saperstein (1996) 50% Placebo Leuchter et al (2002) changes in brain activation APA (1998) Equal to Psychotherapy – More cost effective – Less side effects l Prescription privledges? – http: //www. apa. org/apags/profdev/prespriv. html
Pharmalogical Treatments “Trials” l Tricyclic antidepressants ($15/month) – Imipramine, Noratriptyline, Desipramine & Amitriptyline l MAO Inhibitors*- ($15/month) – Nardil, Parnate & Marplan: 4 -5 week build-up l Heterocyclic antidepressants ($50 -120/month) – 4 to 8 weeks to produce effect – SSRI’s (Prozac, Zoloft, Celexa) – Dopamine specific reuptake inhibitors (Wellbutrin) l Lithium (for Bipolar D/O)
Response to Pharmacological Treatment l Typical 3 part response – Sleep improves – Energy increases – Mood improves l l Suicide potential greatest after energy increases, but before mood improves Who Rx’s most antidepressants? – Problems? l Consider side effect profile
Predictors of Response to Antidepressant Medication l Positive – Gradual onset – Anorexia with weight loss – Middle, Late Insomnia – Psychomotor retardation l Negative – Multiple prior episodes – Delusions & more “complicated” problems
Outcome of Antidepressant Treatment Average duration of MDD= 6 months l 66% with MDD recover within 1 year and 80% recover within 2 years l Among recovered patients, 33% will relapse in 1 year; 75% will relapse in 5 years l Double depression (MDD + Dysthymia) doubles relapse rate l Only 15% of hospitalized will not relapse l
Critical Treatment Components l Psychoeducation – Ex. Abrupt stopping can cause severe side effects and intensify the depressive symptoms. l l Increased structure Decreased stress Rapport and instillation of hope Psychotherapy and pharmacotherapy is most effective, especially for severe levels of depression – 80% of pts. receiving some combination of therapy and medication made significant improvements (Little, et al, 1999 AJP: 155)
Tricyclic Antidepressants MOA: inhibit the NE reuptake l Try for 6 months then taper if Sx. abate l MUST monitor l – mood – weight – BP changes (usually lower) – compliance
Trycyclic Side Effects l Muscarinic receptor blockade (anticholinergic) – dry mouth, constipation, sedation, fatigue – Loss of libido and/or sexual dysfunction – Imipramine, Nortriptyline and Desipramine l Histimic receptor blockade – sedation and weight gain l Alpha-adrenergic receptor blockade – Postural hypotension – Confusion and delirium in the elderly
Sx. of TCA withdrawal Loose stools l Urinary frequency l Headache l Hypersalivation l
SSRIs Becoming most widely prescribed antidepressants l Relatively benign side effect profile l Examples: Prozac (Fluoxetine) and Zoloft (Sertraline); Lexapro (Escitalopram) l Very popular in primary care l Also used with OCD and Anxiety D/Os l
Dopamine Dysfunctional mesolimbic pathway & hypoactive D 1 receptors l Associated with lower levels in depression and higher levels in mania l Ldopa (PD) leads to depression l Tyrosine, Amphetamine & Wellbutrin reduce Dep. Sx. and increase Dopamine l
Prozac l Advantages – Most limited and transient side effect profile – little sedation, weight gain and hypotension – minimal overdose risk l Disadvantages – long half life, psychotic Sx. -drug interactions, child/adolescent contraindications and expensive $ (110/month)
Prozac continued l Drug-Drug Interactions – Increases plasma levels of TCA’s and neuroleptics – Hypermetabolic syndrome with MAOI’s l Side Effects – GI, anxiety, insomnia, headaches, tremor, agitation, insomnia, anorexia, loss of libido and or sexual dysfuntion – Least likely to cause sedation
Symptoms of Serotonin Withdrawal Flu-like (fatigue, nausea, loose stools) l Lightheadedness/dizziness l Uneasiness/restlessness l Sleep and sensory disturbances l Headache l l Dx. Confirmed when Sx. remit after restarting SSRI (usually 12 -24 hours)
Electroconvulsive Therapy Controversies l Progress l Side effects l Efficacy l
Women & Depression l l l Women 2 x likely to be diagnosed, especially younger women Depression is misdiagnosed 30 to 50 % of the time 70% of Rx’s given to women, often without proper monitoring l l Higher rates of physical and sexual abuse Needs – More Prevention – More Research of barriers to treatment – More research on differential risk
Depression and African Americans Higher risk due to SES l Misdiagnosis l – Mistrust of medical system – Cultural barriers – Primary reliance on family and church – “Masked” by medical conditions, somatic complaints or substance abuse – SES limiting access to medical care
African American Attitudes toward depression (National Mental Health Association, 1996) l l l 63% (vs. 54%) “depression is a personal weakness” Only 31% believed depression is a health problem Only 20% said they would seek treatment Only 25% connected change in eating habits or sleep with depression; 16% irritability Only 33% said they would take medication for depression (vs. 69% of general population) 67% believed prayer & faith alone would successfully treat depression “almost all of the time or some of the time. ”
Depression and the Elderly l Depression is NOT a normal part of aging, although 58% of elders believe this 6 million affected, most women, < 10% tx’d 15% in community vs. 25% in ECFs Often misinterpreted as medical condition Elders with comorbid depression have 50% higher health care costs; Depression is often secondary 40% experience reoccurrence Only 38% believe it is a “health problem” Only 42% would seek professional help ECT efficacious l Polypharmacy & Undermedication l l l l
Suicide & the Elderly Most at risk, 50% higher; 2/3 are due to untreated depression l 20 -25% of all suicides occur in the elderly l EA men over 80 are 6 x more likely l Many have recently visited their PCP l – 20% the same day – 40% within one week – 70% within one month
• • • Suicide Incidence History Age/Gender/Race? Marital Status Life Stress Psychiatric Disorders • Parasuicidal behaviors • Children & Adolescents • Assessment & Prevention • Contracts----Baker Act
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