Depression

Question 1

What is the disease burden of disability in the world rankings?

Answer 1

4th in disease burden worldwide behind perinatal conditions, RIs and HIV/AIDS

Question 2

• Which disease has the highest healthcare costs?
• Which disease/disorder has the highest recognition rate?
• Which disease/disorder is the most treatable?

Answer 2

Question 3

What is the most common psychiatric symptom?

Answer 3

Depression

Question 4

Depression

• What is the 1 year prevalence rate?
• How many people are affected in a given year?

Answer 4

• 1 -year Prevalence Rate
  
  • Major Depression 5%
  • Dysthymic Disorder 5.4%
• In a given year, 11 million people
  
  • 5 million Major Depression
  • 1.8 million Bipolar Disorder

Question 5

Of those patients who suffer from depression, how many are:

• Unrecognized:
• Untreated:
• Diagnosed & Treated:

Answer 5

• Unrecognized: 50%
• Untreated: 25%
• Diagnosed & Treated: 25%

Question 6

How can depression present clinically?

Answer 6

• Multiple Somatic Complaints
• Anxiety
• Cultural Influences
  
  • “Nerves”“Headaches”
    
    • Latino, Mediterranean
  • Weakness, Tiredness, “Imbalance”
    
    • Chinese, Asian cultures
  • “Heartbroken”
    
    • Hopi

Question 7

What are common presenting somatic complaints in patients with depression?

Answer 7

1. Disturbed sleep
2. Tired all the time, “blahs”
3. Headache
4. Malaise
5. Vague abdominal or joint pains
6. Sexual dysfunction or loss of sexual interest
7. “Stressed out”
8. GI complaints (eg, constipation, diarrhea)

Question 8

There is a strong correlation between ______ symptoms and prevalence of psychiatric disorders

Answer 8

There is a strong correlation between positive symptoms and prevalence of psychiatric disorders

Question 9

What 3 medical illnesses have a high prevalence rate with depression?

Answer 9

1. Stroke
2. Cancer
3. Diabetes

• Note: Also Parkinson’s disease, myocardial infarction and rheumatoid arthritis

Question 10

What is the DSM-IV classification of mood disorders?

Answer 10

Question 11

**Major Depressive Episode: **

Symptom Criteria

Answer 11

Minimum 5 symptoms for at least two weeks

• At least 1 of the following 2:
  
  1. Depressed mood (irritable in kids)
  2. Loss of interest or pleasure
• 4 of the following:
  
  1. Weight loss or gain
  2. Insomnia or hypersomnia
  3. Psychomotor retardation or agitation
  4. Fatigue or energy loss
  5. Worthlessness or guilt
  6. Decreased concentration
  7. Death thoughts; suicidal thoughts, plans, acts

Question 12

What are additional criteria for a major depressive episode?

Answer 12

• Not Mixed Episode
• Clinically significant distress or impairment
• Not due to substance or general medical condition
• Not Bereavement

Question 13

DSM-IV Criteria for Major Depressive Episode

“SIG E CAPS”

Answer 13

** > 5 symptoms in the same 2-week period**

1. Sleep: insomnia or hypersomnia
2. Interest: depressed mood,* or loss of interest and pleasure*
3. Guilt: feelings of worthlessness
4. Energy: fatigue
5. Concentration: diminished ability to think or make decisions
6. Appetite: weight change
7. Psychomotor: psychomotor retardation or agitation
8. Suicidality: preoccupation with death, hopelessness

*Must include one of these

Question 14

• What is the importance of screening for depression?
• How can depression be screened for?

Answer 14

• US Preventive Services Task Force recommends screening for depression in practices able to then actively manage patients who screen positive
• 2-question depression screen
  
  1. Over the past 2 weeks, have you felt down or hopeless?
  2. Over the past 2 weeks, have you felt little interest in doing things?
• Patient Health Questionaire (PHQ-9)

A “yes”to either question is a positive screen for depression

Question 15

How is a PH9 scored?

Answer 15

Question 16

One person in the U.S. dies by suicide every….

Answer 16

One person in the U.S. dies by suicide every 17 minutes

Question 17

What are the red flags for suicide?

“IS PATH WARM?”

Answer 17

“IS PATH WARM?”

1. Ideation/threatened or communicated
2. Substance Abuse/excessive or increased
3. Purposeless/no reasons for living
4. Anxiety, Agitation/Insomnia
5. Trapped/feeling no way out
6. Hopelessness
7. Withdrawal from friends, family, society
8. Anger (uncontrolled)/rage/seeking revenge
9. Recklessness/risky acts -unthinking
10. Mood changes (dramatic)

Question 18

What are the 3 stages of bereavement?

Answer 18

1. Shock
2. Preoccupation with the deceased
3. Resolution

Question 19

Bereavement Stage 1: Shock

1. Emotions
2. Somatic
3. Thoughts

Answer 19

1. Emotions
   
   • Numbness
   • Sense of unreality
2. Somatic
   
   • Crying
   • Abdominal pangs/emptiness
   • Sighing
   • Tightness in throat
3. Thoughts
   
   • Denial
   • Disbelief

Question 20

Bereavement Stage 2: Preoccupation with Deceased

1. Emotions
2. Somatic
3. Thoughts
4. Motivational

Answer 20

1. Emotions
   
   • Guilt
   • Anger
   • Sadness
2. Somatic
   
   • Weakness
   • Anorexia
   • Insomnia
   • Fatigue
3. Thoughts
   
   • Dreams
   • Thoughts of the deceased
4. Motivational stage
   
   • Anhedonia
   • Introversion

Question 21

Bereavement Stage 3: Resolution

1. Thoughts
2. Motivational Stage

Answer 21

1. Thoughts
   
   • Think of past with pleasure
2. Motivational Stage
   
   • Regain interest in activities
   • Form new relationships

Question 22

What is the pharmcotherapy for depression?

Answer 22

1. Tricyclic antidepressant (TCA)
2. Selective Serotonin Reuptake Inhibitors (SSRI)
3. Atypical
4. Monoamine Oxidase Inhibitors (MAOI)
5. Others

Question 23

List the Tricyclic antidepressants (TCA) (10):

Answer 23

1. Imipramine (Tofranil)
2. Desipramine (Norpramin)
3. Clomipramine (Anafranil)
4. Trimipramine (Surmontil)
5. Amitriptyline (Elavil)
6. Nortriptyline (Pamelor)
7. Protriptyline (Vivactil)
8. Doxepin (Sinequan)
9. Amoxapine (Asendin)
10. Maprotilene (Ludiomil)

Question 24

What should be conisdered when using tricyclic antidepressants?

Answer 24

• Effective First Line Treatment
• Preferred by Managed Care
• Compliance Issues Due to Side Effects
  
  • Dry mouth
  • Sedation
  • Orthostatic Hypotension
• Cardiac arrythmias with overdose

Question 25

List the Selective Serotonin Reuptake Inhibitors (SSRI) (6):

Answer 25

1. Fluoxetine (Prozac) 2. Sertraline (Zoloft) 3. Paroxetine (Paxil) 4. Citalopram (Celexa) 5. Fluvoxamine (Luvox)-not approved for depression 6. Escitalopram (Lexapro)

Question 26

What should be considered when treating with SSRIs?

Answer 26

* **Dosage, Dosage, Dosage** * **Recurrence** * increase dose or stop * **Side effects** * Headache, dizziness * Nausea, loose stools, constipation * Somnolence or insomnia * Sweating, tremor, dry mouth * Anxiety, restlessness * Sexual Drive * **Persistence** - if at first you don’t succeed

Question 27

List the atypical anitdepressants (7):

Answer 27

1. Bupropion (Wellbutrin/Zyban) 2. Trazodone (Desyrel) 3. Nefazodone (Serzone) 4. Venlafaxine (Effexor) 5. Mirtazapine (Remeron) 6. Duloxetine (Cymbalta) 7. Alprazolam (Xanax)

Question 28

List the Mono-Amine Oxidase Inhibitors (MAOI) (5):

Answer 28

1. Phenelzine (Nardil) 2. Isocarboxazid (Marplan) 3. Tranylcypramine (Parnate) 4. Selegiline patch (Emsam) 5. RIMA: meclobemide, others

Question 29

List the other treatments available for depression (10):

Answer 29

1. Lithium 2. Augmentation therapy * Lithium * T-3 L-triiodothyronine Cytomel 3. Psychotherapy 4. ECT (Electro-Convulsive Therapy) 5. Vagal Nerve Stimulation 6. Transcranial Magnetic Stimulation 7. Deep Brain Stimulation 8. St John’s Wort 9. Sam-E (s-adenosylmethionine) 10. Reboxetine (snri)

Question 30

What are the **5 R's** of the clinical course for depression?

Answer 30

* Response * Remission * Relapse * Recovery * Recurrence