DepressionGaren Polatoglu

A 70-year-old woman presents to her primary care provider

complaining of fatigue for the past 7 weeks. She admits to difficulty

falling asleep, a poor appetite with a 10-lb weight loss, and thoughts

of wanting to die. She admits to having had symptoms similar to these

on several occasions in the past, but “never this bad.” Her medical

problems include asthma and high cholesterol. She uses an albuterol

inhaler only as needed. Which of the following symptoms is necessary

in order to make a diagnosis of major depressive disorder?

a) Depressed mood b) Decreased appetite c) Excessive guilt d) Fatigue e) Suicidal ideation

A 70-year-old woman presents to her primary care provider

complaining of fatigue for the past 7 weeks. She admits to difficulty

falling asleep, a poor appetite with a 10-lb weight loss, and thoughts

of wanting to die. She admits to having had symptoms similar to these

on several occasions in the past, but “never this bad.” Her medical

problems include asthma and high cholesterol. She uses an albuterol

inhaler only as needed. Which of the following symptoms is necessary

in order to make a diagnosis of major depressive disorder?

a) Depressed mood b) Decreased appetite c) Excessive guilt d) Fatigue e) Suicidal ideation

Epidemiology

• Mean age of onset is around 40• Higher in females– Bias in diagnosis?

• Higher in those who are– Single– Divorced/separated

• Family history

Statistics

• 5-10% primary care patients meet criteria

• Lifetime prevalence in 2001 was 16%

• 10-20% if diabetic or heart disease

_______________________________________40% recurrence after 1st episode within 2 years75% recurrence after 2nd episode within 5 years

Differentials

• Hypothyroidism• Parkinson’s disease• Dementia• Pseudodementia• Medications• Tumors• CVA

• Mood Disorders• Substance Abuse• Grief

Major Depressive Episode

• 2 weeks

• Change from previous functioning

• At least 5 of the following

• Episodes are considered separate when there is at least 2 months between present symptoms

Criteria

M - Depressed mood (children irritable)

S – Sleep changesI – loss of interest (anhedonia)G – excessive/inappropriate guilt or worthlessnessE – loss of energyC – Cognition/Concentration (subjective/objective)A – appetite, usually decreasedP – psychomotor agitation or retardationS – SI or recurrent thoughts of death

Physical Examination

• Usually within normal bounds• Psychomotor retardation• Stooped posture• Slow movements• Slow speech• Decreased concentration• Forgetful

MDE is NOT due to:

• General medical condition• Mood incongruent delusions/hallucinations• Drugs or medicine• Bereavement

_____________________________________Must impair social, occupational, life functioning

Specifiers

• Melancholic• Atypical• Catatonic• Postpartum• SAD

• Depression with Psychotic features– Delusions/hallucinations of guilt/worthlessness

Atypical Depression

• Mood Reactivity (happy with positive events)• 2 of the following:– Increased appetite, weight gain– Hypersomnia– Leaden paralysis– Interpersonal rejection sensitivity

Comorbidities

• Anxiety disorders• Cognitive disorders (e.g. dementia)• Eating disorders• Somatoform disorders• Personality disorders• Sleep disorders• Substance use disorders

Assess for SI

• Presence of suicidal or homicidal ideation, intent, or plan

• Access to means for suicide and the lethality of those means

• Presence of psychotic symptoms, command hallucinations, or severe anxiety

• Presence of alcohol or substance use• History and seriousness of previous attempts• Family history of or recent exposure to suicide

Treatment

• SSRI / SNRI / TCA / MAOI• DA/NE reuptake inhibitors• Psychotherapy/CBT (for mild/moderate)_______________________________________

• One study showed better efficacy for escitalopram and sertraline (SSRI’s)

Pick one that works, while minimizing SE’s

Tx Duration

• 6-9 months

• 37% relapse within 12mo of stopping• Risk factors include:– Subthreshold depressive Sx after 7mo of therapy– History of 2+ MDEs

Hamilton Rating Scale

• Useful in gauging the progression/recovery of depression in patients

• Originally had 17 items

• Current version have up to 29 items_________________________________________

_http://healthnet.umassmed.edu/mhealth/HAMD.pdf

A 78-year-old man presents with 4 weeks of significant depression following the sudden, unforeseen death of his wife of 35 years. He reports difficulty sleeping, a 10-lb weight loss, frequent crying spells, and profound guilt over surviving her. For the last several days, he has been convinced that his body is literally decaying. He admits to seeing his wife’s face during the day, as well as hearing her voice telling him to kill himself and join her.

A 78-year-old man presents with 4 weeks of significant depression following the sudden, unforeseen death of his wife of 35 years. He reports difficulty sleeping, a 10-lb weight loss, frequent crying spells, and profound guilt over surviving her. For the last several days, he has been convinced that his body is literally decaying. He admits to seeing his wife’s face during the day, as well as hearing her voice telling him to kill himself and join her.

Major Depression w/ Psychotic Features

Thank you!