Depressive Disorders

Question 1

How is MDD defined? List the symptoms

Answer 1

1. Five or more of the nine symptoms that are present during same 2-week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure
2. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
3. Episode is not attributable to physiological effects of a substance or to another medical condition;

SIGECAPS
S: sleep disturbance (insomnia/hypersomnia)
I: interest/pleasure reduction (subjective or observation)
G: guilt, feelings of worthlessness
E: energy loss, fatigue
C: concentration/attention impairment (subjective or observed)
A: appetite changes (increase or decrease)
P: psychomotor symptoms (agitation or reduction that’s observed)
S: suicidal ideation (recurrent thoughts, or even an attempt)

Question 2

What can be used to differentiate between normal sadness and depression?

Answer 2

At least one of the following (SWAG):

1. Suicidality (serious thoughts or attempts at killing oneself)
2. Weight loss (>5% loss of body weight without medical cause)
3. Anhedonia (loss of pleasure/interest in previously enjoyable activities)
4. Guilt (feeling responsible for negative life events without reason)

Question 3

Other characteristics of MDD?

Answer 3

1. Atypical depression (more likely to have weight gain and hypersomnia; also leaden paralysis, carb cravings, rejection sens)
2. Pseudodementia
3. Diurnal variation (more depressed in AM than PM, or MELANCHOLIC type depression)
4. Psychomotor symptoms (physical complaints like body aches, headaches; agitation vs. retardation, and vegetative depression)
5. Seasonal affective disorder (MDD can come along with winter, see atypical symptoms, treat with full-spec light exposure, psychotherapy, antidepressants)
6. Masked depression (someone who’s depressed will have vague physical ailments but in denial/unaware of depression; they are STOIC; seek care for psychomotor or somatic symptoms and not depression; think more elderly and OC personalities)

Question 4

DD of MDD?

Answer 4

1. Hypothyroidism
2. Cushing’s
3. Anemia
4. Brain injury, stroke
5. Vit deficiency (B12, folate, Vit D)
6. OSA

Question 5

Etiology of MDD

Answer 5

1. Monoamine deficiency
2. Monoamine receptor excess theory
3. Loss of neurotrophic factors and degen
4. Genetics (serotonin transporter gene);
   psychosocial factors: ability to cope with life stressors, low self-esteem, personality traits, addiction, learned helplessness, catastrophic loss, etc.

Question 6

Occurrence of MDD?

Answer 6

1. Women more so than men
2. Women more likely to seek help/treatment
3. Higher risk for ELDERLY who are widowed or chronically ill
4. Co-morbidity of substance abuse, generalized anxiety

Question 7

Treatment of antidepressants?

Answer 7

1. SSRI’s, SNRI’s, NDRI’s, MAOI’s (the front line agents, with less severe SE’s)
2. TCA;
   Sedating antidepressants (e.g. trazodone, mirtazapine) that block 5HT2 receptors and H1 receptors instead of using SSRI; mirtazapine increases NE by blocking alpha-2a NE receptor;
   if antidepressants not enough, use LITHIUM, thyroid hormone, atypical antipsychotic (SGA)

Question 8

If antidepressants are too slow…

Answer 8

think electroconvulsive therapy:
SHOCK TREATMENT
1. effective for severe depression (especially if non-responsive to meds)
2. Used if antidepressants cannot be used due to toxicity/SE’s, or if they fail
3. Used when immediate resolution of symptoms is needed (suicidal/psychotic patients)

Question 9

Other neurostim techniques?

Answer 9

1. Vagus nerve stimulation (goes to NTS then LC and RN; can get hoarseness as SE with damage to recurrent laryngeal and worried about permanent hoarsness)
2. Transcranial magnetic stimulation (good for mild-moderate depression)
3. Deep Brain stimulation (disconnect hot and cold regions of brain, but worried about stroke and infection)
4. Transcranial Direct Current Stimulation

Question 10

Psychological treatments:

Answer 10

Think family, interpersonal, psychoanalytic/psychodynamic, behavioral, cognitive therapies

Question 11

Ways to deal with neurophys of depression?

Answer 11

1. Try and get more SR in system (make more neurotrophic factors)
2. Try and downregulate the number of receptors for SR
   need balance between number of receptors and amount of NT

Question 12

Genetic and environmental risk factors in depression?

Answer 12

65% unique environmental, 35% genetic factors;

Question 13

Theory on how depression could come about at neuronal level?

Answer 13

1. Stress increases glucocorticoids and decreases BDNF
2. Atrophy/death of neurons (decreased dendritic branching);
   break cycle by increasing 5-HT and NE, decrease glucocorticoids, increase BDNF, increased survival and growth

Question 14

General rule of thumb for depression neuroanatomy?

Answer 14

Hypoactive DLPFC, hyperactive amygdala!!!

Cold front, hot in middle