Depression

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Author:
wcameron
ID:
207899
Filename:
Depression
Updated:
2013-03-18 21:55:10
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Depression
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Description:
dx criteria for depression
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  1. DSM-IV Criteria for Major Depression
    > or = 5 symptoms (SIG E CAPS) PLUS depressed mood or anhedonia, causing sign.dysfunction for at least 2 weeks
  2. DSM-IV Criteria for Minor Depression
    2-4 symptoms PLUS depressed mood, anhedonia causing sign.dysfunction, for at least 2 weeks
  3. Depression Criteria (SIG E CAPS) acronym
    • S: suicidal thoughts
    • I:  interest decrease in almost all activities
    • G: guilt; worthlessness/hopelessness

    E: energy decrease

    • C: concentration problems
    • A: appetite/weight change
    • P: psychomotor agitation/retardation
    • S: sleep disturbance/decreased sexual desire
  4. DSM-IV Criteria for Dysthymia
    3-4 sx PLUS depressed mood, causing sign. dysfunction for > or = 2 years
  5. Most common presenting symptoms of depression
    • Fatigue
    • sleep disturbances
    • pain
    • anxiety, irritability
    • dysphoric (loss of interest, social withdrawal, irritability)
  6. Women and depression
    women are twice as likely to suffer from mood disorders, eating disorders, more likely to attempt suicide
  7. Periods of increased risk of depression in women
    premenstrual phase, immediate postpartum period, perimenopause (5 yrs before & 5 years after)
  8. Risk factors for depression in women
    • - use of O.C. (especially high in progesterone)
    • - infertility treatments
    • - persistent psychosocial stressors (loss of job)
    • - threat or loss of social support system
  9. Criteria for premenstrual dysphoric disorder
    • - onset 1-2 weeks before menstrual flow
    • - impaired fx or interpersonal relationships
    • - occurs in 2-9%
    • - age of onset usually late 20's, can worsen w/ age
  10. Postpartum Blues
    • Incidence: 60-70% of post-partum women
    • Peak: 3-7 days, lasts < 2 weeks
    • Risk Factors: primiparous, hx of PMS
    • Tx: reassurance to pt., educate family
  11. Postpartum depression
    • Occurs: 8-15% of women, >20% of adolescent mothers
    • Onset: 60-70% within 6 weeks
    • Symptoms: excessive worry, somatic sx in excess or w/o physical cause
  12. Late-life depression: Prevalence rates
    Highest rates in LTC sites, stroke pts., then MI pts.

    Lowest rates in community elderly then the general population
  13. Differentiating Depression from Grief (Major Depression)
    Guilt & self blame

    > 6 months duration

    May be incapacitated

    May be suicidal

    Unremitting
  14. Differentiating Depression from Grief (Grief reaction)
    guilt & self blame

    < 6 months duration

    can usually function

    Usually NOT suicidal

    Exacerbations/remittance
  15. When to consider pathological grief reaction...
    previous dx of depression

    lasts longer than 6-12mos

    • Results in: 
    •      social withdrawal
    •      functional decline

    MEN ARE AT HIGHER RISK OF PATHOLOGICAL GRIEF REACTION than women, following a spouse's death
  16. Subsyndromal depression
    pt. has clinically significant depressive symptoms but does not meet criteria by time, duration, quantity or severity criteria.

    Use of psychotherapy may benefit these patients.
  17. Distinctive diagnostic features of depression in elderly
    • - chronic pain
    • - anxiety
    • - memory impairment: forgetful
    • - motor slowing
    • - excessive functional disability
    • - Men: anger, apathy, anhedonia w/o sadness
    • - women: somatic sx, sadness
  18. U.S.P.S.T.F. Recommendations for Screening for Depression
    Screening tool to be filled out while waiting to be seen.

    OR

    Clinicians evaluate pts. when the clinical presentation triggers the suspicion of depression.
  19. USPSTF Depression Screening questions
    1. Over the past 2 weeks (month), have you ever felt down, depressed, or hopeless?

    2. Over the past 2 weeks (month), have you felt little pleasure or interest in doing things?

    Sensitivity 96%          Specificity 57%
  20. Time course of clinical response to antidepressant therapy
    2 weeks:  initial response

    4 weeks: substantial response

    8-12 weeks: maximal benefit

    Maintenance: 

    9-12 months minimum tx at full dosage

    Relapse risk up to 70% if early D/C
  21. When do pts. often stop taking antidepressant meds?
    • 1 month: 72% compliant
    • 3 months: 56% compliant
  22. Antidepressant use and weight gain (long-term)
    Weight loss: Buproprion, fluoxetine

    Weight gain: citalopram, mirtazapine, nefazodone, paroxetine (worst), sertraline
  23. SSRI Withdrawal Syndrome
    Most common sx: dizziness, irritability, vivid dreams, lethargy, panic-like attacks

    • - paroxetine (20% of the time)
    • - fluoxetine (0% of the time for withdrawal)
  24. Recurrence rates of depression
    1 year: 33%

    2 years: 50%

    8 years: 75%
  25. Long-term maintenance Rx of depression
    Advisable after 2 episodes of MDD who: 

    • - have 1st deg. family hx of recurrent MDD
    • - hx of recurrence w/in 1 year after previous effective rx d/c'd
    • - onset of MDD < age 20
    • - severe, sudden or life-threatening in both episode w/in past 3 years.
  26. When to refer...
    Pts. with severe symptoms

    • - suicidal tendencies/hx of attempts
    • - bipolar disorder
    • - atypical disorder
    • - psychotic depression
    • - pts. who have had drug-drug reaction or who will need complex therapy
    • - pts. who are tx resistant
  27. SSRI-induced dysfunction
    changes in sexual response occur because of increased serotonin activity at the 5-HT2 receptor site causing:

    • - loss of libido
    • - delayed time to orgasm
  28. Strategies for the treatment of antidepressant-induced sexual dysfunction
    • - baseline eval.
    • - educate on S.E.
    • - tolerance to the medication
    • - switch antidepressant
    • - drug holiday (d/c after thursday dose, restart Sunday by noon)

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