Depression

Question 1

How many people w/ depression get treatment? Adequate treatment?

Answer 1

50% get treatment. Just 20% get adequate treatment.

Question 2

What is ratio of suicide attempts / completions?

Answer 2

5:1

Question 3

Risk factors for suicide:
#1 risk
What percentage of pxs w/ bipolar attempt?
Men vs women
Fastest growing population
Lower in which populations?
Protective factors
Genetic contribution
Age factors

Answer 3

• Previous attempt is #1 risk factor
• Other psychiatric disorders increase risk. 50% of pxs w/ bipolar disorder attempt.
• Women are 3x more likely to attempt, men are 3-4x more likely to complete suicide. Men are more likely to use firearms and be abusing drugs / alcohol.
• Older adults are fastest growing population who are committing suicide.
• Suicide rates are lower in AA’s, Hispanics, and Asians, compared to whites and Native Americans.
• Marriage is protecting – Double risk in single men, 4-5x risk in divorced, widowed, or separated men compared to married men.
• Strong religious beliefs and responsibility for children are also protective.
• Family history (50% genetic contribution)
• Among those who have committed suicide, those 30 are more likely to have a mood disorder.

Question 4

Aspects of proper suicide assessment

Answer 4

General demographics, risk factors, current mental status, prior SI, and questioning about ideation, intent, and access to means

Question 5

Medical Conditions causing depression

Answer 5

• Endocrine disorders – Hypothyroidism, Addison’s disease, Cushing’s disease
• Neurological disorders – Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, epilepsy
• Nutritional disorders – deficiency of vitamin B12 or folate
• Neoplasia – especially pancreatic cancer and tumors in the frontal lobes
• Cerebrovascular disease – especially strokes in the left frontal lobe
• Infection – HIV/AIDS, neurosyphilis
• Sleep disorders – Sleep apnea cardiovascular disease.

Question 6

Substances / meds causing depression

Answer 6

Alcohol, opioids, stimulants, sedatives / hypnotics, corticosteroids, antihypertensives (beta blockers), or antibiotics

Question 7

What percentage of depression is genetic? Which genes?

Answer 7

Heritability of major depression is 35-40%.

Genes involve 5HT-TPR, BDNF, and COMT.

Question 8

Diathesis-stress framework

Answer 8

Person may inherit vulnerability to express certain behaviors (diathesis), which are activated only under certain conditions (stress)

Question 9

What is the chemical cause of anhedonia?

Answer 9

Loss of dopaminergic system

Question 10

Risk factors for depression

Answer 10

Prior personal history (strongest risk factor), family history, female, stressful life events, lacking social support, childhood abuse, death / divorce of parent, substance abuse, anxiety, and medical conditions.

Question 11

PHQ-2 Screen

Answer 11

• “In the last 2 weeks, have you felt down, depressed or hopeless?”
• “In the last 2 weeks, have you felt little interest or pleasure in doing things?”

Question 12

Criteria for major depressive episode
Vegetative sxs (5)
Pseudodementia

Answer 12

• Discrete period of abnormal mood, cognitions, and behavior lasting at least 2 weeks. Core sxs are dysphoric mood and anhedonia.
• Vegetative sxs include changes in appetite, weight, sleep, loss of energy, or psychomotor agitation / retardation.
• Pseudodementia – seen in older adults who have severe depression inhibiting their ability to think or concentrate

Question 13

DSM Criteria for MDD

Answer 13

• A – Need 5 or more of the following for at least 2 weeks (one must be #1 or 2):
• 1) depressed mood
• 2) diminished interest / pleasure (anhedonia)
• 3) weight loss / gain or change in appetite
• 4) insomnia / hypersomnia
• 5) psychomotor agitation / retardation
• 6) fatigue
• 7) feeling worthless / excessively guilty
• 8) decreased concentration / indecisiveness
• 9) suicidal ideation
• B – The sxs cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• C – The episode is not attributable to the physiological effects of a substance or other medical condition.
• D – Not better explained by other psychiatric disorder
• E – There has never been a manic or hypomanic episode.

Question 14

SIGECAPS

Answer 14

• change in Sleep
• loss of Interest
• Guilt
• lack of Energy
• poor Concentration
• change in Appetite
• Psychomotor retardation or agitation
• Suicidal ideation

Question 15

Peri / Postpartum depression

Answer 15

Begins w/in 1 month of delivery. Psychosis may also be involved. Different than “baby blues”, which are transient, low-level mood changes w/in 10 days of giving birth.

Question 16

Who is at higher risk for seasonal depression (SAD)?

Answer 16

More common in women, younger pxs, and those at higher altitude

Question 17

Criteria for persistent depressive disorder (AKA dysthymia)

Answer 17

Lasts at least 2 years. Called “double depression” when it occurs on top of MDD. At least 2 of the following sxs must be present:
• poor appetite or overeating;
• insomnia or hypersomnia;
• low energy or fatigue;
• low self-esteem;
• poor concentration or difficulty making decisions; or
• feelings of hopelessness.

Question 18

Prognosis for depression

Answer 18

1 year after onset 40% of pxs still meet full criteria and 20% meet partial criteria.

Question 19

4 main brain areas involved in depression

Answer 19

PFC, anterior cingulate, amygdala, and hippocampus.

Question 20

Role of amygdala in depression

Answer 20

Important for emotional learning, emotional memory, vigilance detection, and emotion regulation

Question 21

Role of hippocampus in depression

Answer 21

Emotional cognition

Question 22

Role of insular cortex in depression

Answer 22

Detection of visceral states

Question 23

How does PFC regulate emotion?

Answer 23

PFC normally down regulates activity in amygdala. This circuit is inhibited in pxs w/ depression. High amygdala activity –> HPA activation.

Question 24

Which NT’s act in long-distance signaling?

Answer 24

5HT, NE, DA, and Ach

Question 25

Where is 5HT produced?

Answer 25

Raphe nuclei

Question 26

Where is NE produced?

Answer 26

Locus ceruleus

Question 27

Which NT's act in local signaling?

Answer 27

Glutamate and GABA

Question 28

Which parts of the brain inhibit HPA activation?

Answer 28

Hippocampus and anterior cingulate cortex

Question 29

Where does cortisol bind to cause negative feedback?

Answer 29

Hippocampus, PFC, hypothalamus, and pituitary. Defects in this negative feedback are seen in severe depression.

Question 30

What percentage of pxs are helped by antidepressants?

Answer 30

60-70%

Question 31

Adjunctive meds to antidepressants (5)

Answer 31

Benzos (to treat insomnia), antipsychotics, thyroid hormone, lithium, and psychostimulants.

Question 32

Which AA is a precursor for 5HT | Which foods?

Answer 32

Tryptophan | Found in turkey, nuts, tofu, cheeses, fish, oats, eggs, beans, etc

Question 33

Classic Triad of Serotonin Syndrome Severe sxs Tx

Answer 33

Triad: neuromuscular excitation (clonus / hyperreflexia), ANS excitation (hyperthermia / tachycardia), and altered mental state. If severe, rhabdomyolysis (may cause kidney damage), disseminated intravascular coagulation, and adult respiratory distress syndrome may occur. Tx w/ stopping meds, hydrating, active cooling, and sedation.

Question 34

Which drugs reduce risk of suicide?

Answer 34

Lithium (bipolar) and clozapine (schizo)

Question 35

4 Neuromodulation / Somatic Treatments for depression

Answer 35

* Electroconvulsive therapy – most effective treatment for severe, refractory, or psychotic depression. Safe during pregnancy. Side effects include memory loss and cardiac problems. * Vagal nerve stimulation * Repetitive transcranial magnetic stimulation (rTMS) * Deep brain stimulation (requires neurosurgery)