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What is the recomendation of pyschatric screen by USPSTF
Every adult should be screen for depression but half still remain undiagnosed.
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What is the precentage of patient with depression seen in PCP
1/3 of patient seen by PCP have depressive symptoms.
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Is there a significant distribution seen among genders
Female are more likely to have depression than their counterpart.
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What are possible presentation of depression
Somatic presentation of HA or pain are common symptoms associated with emotional state.
- Additional somatic symptoms are
- fatigue
- insomnia
- GI (pepsia)
- Vague ache and pain
- Heighten impairment not associated to current presentation
- Refactory symptoms not resolved by standard treatment
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Is it important to do through physical exam
Yes. Purpose of r/o physiological and pathological changes that could be etiology of s/s.
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In what comorbid condition is depression common associated with
Chronic pain, HIV, and fibromyalgia
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Which professional is most likely to be informed of depressive emontions first
PCP are commonly first to hear of emotional distress and usually to begin treatment.
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The etiology of depression is
Multifactorial
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Is genetic an etilogy of depression
Yes. Study have shown high concordance rates among family members with MAJOR DEPRESSION and BIPOLAR
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What neurotransmitter are associated with depression
Serotoin, dopamine, GABA, norepinephrine
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What are possible trigger related to depression
- Death
- Divorce
- Loss of job
- Hormonal influence
- Women more common
- Major deprssion s/p postpartum
- Premenstrual dysphoric disorder
- Medical conditions
- CVA
- Lupus
- Pancreatic CA
- Endocrine
- Hypothyroid
- Crushing (adrenal)
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What do PCP use as a screening tool
PCP use mood module of the Primary Care Evaluation of Mental Disorder to increase detection of condition
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What does mood module of the Primary Care Evaluation of Mental Disorder evaluate
What is it based on
- SIGE CAPS
- Sleep
- Intrest
- Guilty
- Energy
- Concentration
- Appetite
- Pyschomotor
- Aggitation/retardation
- Suicide
Based on Diagnostic and Stat Manual of Mental Disorder (DSM)
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In additional to excluding hormonal and pathological etiology what else should be considered
- Drug abuse
- Alcohol
- Withdrwal > depressive state
- Cocaine (<cathoamine = depressive state)
- Withdrwal > depressive state
- Medication
- Reserpine
- Beta Blocker
- Time
- season
- Pyschosocial
- bereavement
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Dysthymia is
Chronic low grade depressive state > 2 yrs w/o exact recogition of event or trigger. Must evaluate for additional/coexisting personality disorder.
Very responsive to treatment with SSRI
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What must be considered when s/s of major depression exist?
- Inquire about possible manic episodes.
- Must consider Bipolar affective disorder.
- Treatment of Bipolar requires mood-stablizer and not a monotherapy antidepressant (major depression therapy).
- Rationle: treatment of Bipolar with only monotherapy antidepressant causes cycling of manic episodes.
- Must differentiate between Bipolar and Major depression
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Why is important to inquire about time and season of presenting episodes in depression
- Seasonal Affective Disorder is perpetuated by seasonal changes. Presentation of depressive on-set occurs in FALL and Early Winter with remission in the Spring.
- No pharmalogical therapy needed.
- Light therapy is benificial
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Depressive s/s in a women
- Consider mentrual cycle.
- Luteal phase "yes"
- Premenstrual Dysphoric Disorder
Treat with SSRI
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Patient having distress and functional impairment precipitated by identfiable stressor
Adjustment disorder with depress mood if criteria for Major depression is not fullfilled.
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Pharmocolgical facts with treatment
- -No single agent proven to be better
- (66% chance or responing to agent)
- -efficay of antidepressant and family members
- -daily dosing (Ideal)
- -cost
- -s/e (issues)
- -interactions
- -low dosing intially with titration
- -several weeks.
- -no abrupt stopping
- -suicidal concerns
- -Must continue theraputic dosing 6mo to 1 yr after theraputic lvls to prevent relapping
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What determines indefinite treatment with antidepressant.
Having 3 or more episodes of Major Depression
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Which are the most common prescribed antidepressant
SSRI
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S/E of SSRI
- -GI
- -HA
- -drowsiness
- -tremor
- -anxiety
- -sexual dysfuction (dose related)
- -hyperhydrosis
- Inappropriate antidiuretic horome
- Flu like symptoms during withdraw/ must tritrate dose slowly
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Alternative therapy
- herbal
- -St John 300 to 1000mg
- -Can inhibit CYP3A4 in liver
- -SamE 150-2400mg
- (S-adenosyl-methionine)
- Psychotherapy
- -Cognitive behavioral therapy
- -support group
ideal treatment is combo of phramo and pyscho therapy
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Bipolar affective disorder treatment
- Mood stablizer agent
- -Lithium=(no ACE, ARB, NSAID,renal, hypothyroid)
- -Valproic acid (depakote) Hepatoxic, POCS Pancreatitis, thrombocytopenia
- -carbamazepone (tegretol) aplstic anemia, SJS, Hyponatermia,
- -Lamotrigine (lamictal) SJS
- -Olanzapine DM2, weight gain, HLD
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Risk factor for suicide are
- Demo:
- White, female more but male more successful, loner, divorced/widowed or single, older
- HX or symptoms:
- Prior attempts, detailed plan, hopelessness, family HX of suicide, mentioned of the act, recent pysch troubles/hospitalization, own guns.
- Comorbid:
- Chronic illness, substance abuse, Axial II or II pyshc dx.
- Psychsocial:
- acut alcohol intox, leagal problems, loss of job, financial problem, estranged from family, bereavement, lack of social support
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