Transcript DSM-IV

Mood Disorders
Mental Problems
Related to Mood
Mood episodes
 Mood Disorders
 Specifiers
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Mood
Sustained emotion that colors the way we
view life.
 Mood D/O’s seen in 20% of women and
10% of men*
 50% of typical mental health practice
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Male Risk Factors
Isolation
 Anhedonia
 Limited Physical Activity
 Limited Self-reflection
 Denial/Pessimistic
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Mood Disorders
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Major Depressive Episode
Dysthymic
Depressive Disorder NOS
Manic Episode
Bipolar I
Bipolar II
Cyclothymic
Bipolar Disorder NOS
Other Mood Disorders
Mood Disorder due to GMC?
 Substance-Induced Mood Disorder
 Mood Disorder NOS
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Other causes of Depressive
and Manic Symptoms
Schizoaffective Disorder
 Cognitive Disorders with depressed mood
 Adjustment Disorder with Depressed Mood
 Personality Disorders
 Bereavement
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Specifiers
With Atypical Features*
 With Melancholic Features
 With Catatonic Features
 With Postpartum Onset
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Course of Recurrent
Episodes
With/without Full Interepisode Recovery
 With Rapid Cycling
 With Seasonal Pattern
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Major Depressive Episode
Quality of depressed mood
 Duration
 Symptoms
 Impairments
 Exclusions
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Depressive Symptoms
Depressed mood
 Anhedonia
 Lost appetite and weight
 Insomnia
 Psychomotor retardation
 Agitation
 Suicidal ideation
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Theories of Depression
Cognitive (Beck)
 Learning (Seligman)
 Neuroendocrine
 Circadian Rhythm Hypotheses
 Neurotransmitter
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Cognitive Aspects of
Depression
Pessimism (underestimates likelihood of
success)
 Lack of Self-esteem (underestimate the
value of past achievements)
 “It doesn’t matter” (responses won’t make
a difference)
 Biased judgement (toward negativism)
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Neuroendocrine
Abnormalities
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Hypercorticolism (dysfunction in HAP axis)
Dexamethasone suppression test
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basis of test-diagnostic and treatment marker
procedure
Problems
Utility?
Blunting of plasma growth hormone
Blunting of serotonin-mediated increase in plasma
prolactin
Circadian Rhythm
Abnormalities
Patterns of insomnia and hypersomnia
 Diurnal fluctuations in mood
 Seasonal pattern depression (ultradian)
 Abnormalities in sleep architecture
 Impact of:
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– antidepressants on sleep architecture
– phototherapy
– reset biological clocks (endogenous zeitgebers)
Medication: Placebo?
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Kirsh et al (1999) 80 % Placebo
Saperstein (1996) 50% Placebo
Leuchter et al (2002) changes in brain activation
APA (1998) Equal to Psychotherapy
– More cost effective
– Less side effects
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Prescription privledges?
– http://www.apa.org/apags/profdev/prespriv.html
Pharmalogical Treatments
“Trials”
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Tricyclic antidepressants ($15/month)
– Imipramine, Noratriptyline, Desipramine & Amitriptyline
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MAO Inhibitors*- ($15/month)
– Nardil, Parnate & Marplan: 4-5 week build-up
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Heterocyclic antidepressants ($50-120/month)
– 4 to 8 weeks to produce effect
– SSRI’s (Prozac, Zoloft, Celexa)
– Dopamine specific reuptake inhibitors (Wellbutrin)
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Lithium (for Bipolar D/O)
Response to
Pharmacological Treatment
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Typical 3 part response
– Sleep improves
– Energy increases
– Mood improves
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Suicide potential greatest after energy increases,
but before mood improves
Who Rx’s most antidepressants?
– Problems?
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Consider side effect profile
Predictors of Response to
Antidepressant Medication
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Positive
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Gradual onset
Anorexia with weight loss
Middle, Late Insomnia
Psychomotor retardation
Negative
– Multiple prior episodes
– Delusions & more “complicated” problems
Outcome of Antidepressant
Treatment
Average duration of MDD= 6 months
 66% with MDD recover within 1 year and
80% recover within 2 years
 Among recovered patients, 33% will relapse
in 1 year; 75% will relapse in 5 years
 Double depression (MDD + Dysthymia)
doubles relapse rate
 Only 15% of hospitalized will not relapse
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Critical Treatment
Components
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Psychoeducation
– Ex. Abrupt stopping can cause severe side effects and
intensify the depressive symptoms.
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Increased structure
Decreased stress
Rapport and instillation of hope
Psychotherapy and pharmacotherapy is most
effective, especially for severe levels of depression
– 80% of pts. receiving some combination of therapy and
medication made significant improvements (Little, et al,
1999 AJP: 155)
Tricyclic Antidepressants
MOA: inhibit the NE reuptake
 Try for 6 months then taper if Sx. abate
 MUST monitor
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mood
weight
BP changes (usually lower)
compliance
Trycyclic Side Effects
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Muscarinic receptor blockade (anticholinergic)
– dry mouth, constipation, sedation, fatigue
– Loss of libido and/or sexual dysfunction
– Imipramine, Nortriptyline and Desipramine
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Histimic receptor blockade
– sedation and weight gain
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Alpha-adrenergic receptor blockade
– Postural hypotension
– Confusion and delirium in the elderly
Sx. of TCA withdrawal
Loose stools
 Urinary frequency
 Headache
 Hypersalivation
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SSRIs
Becoming most widely prescribed
antidepressants
 Relatively benign side effect profile
 Examples: Prozac (Fluoxetine) and Zoloft
(Sertraline); Lexapro (Escitalopram)
 Very popular in primary care
 Also used with OCD and Anxiety D/Os
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Dopamine
Dysfunctional mesolimbic pathway &
hypoactive D1 receptors
 Associated with lower levels in depression
and higher levels in mania
 Ldopa (PD) leads to depression
 Tyrosine, Amphetamine & Wellbutrin
reduce Dep. Sx. and increase Dopamine
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Prozac
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Advantages
– Most limited and transient side effect profile
– little sedation, weight gain and hypotension
– minimal overdose risk
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Disadvantages
– long half life, psychotic Sx.-drug interactions,
child/adolescent contraindications and
expensive $ (110/month)
Prozac continued
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Drug-Drug Interactions
– Increases plasma levels of TCA’s and
neuroleptics
– Hypermetabolic syndrome with MAOI’s
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Side Effects
– GI, anxiety, insomnia, headaches, tremor,
agitation, insomnia, anorexia, loss of libido and
or sexual dysfuntion
– Least likely to cause sedation
Symptoms of Serotonin
Withdrawal
Flu-like (fatigue, nausea, loose stools)
 Lightheadedness/dizziness
 Uneasiness/restlessness
 Sleep and sensory disturbances
 Headache
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Dx. Confirmed when Sx. remit after
restarting SSRI (usually 12-24 hours)
Electroconvulsive Therapy
Controversies
 Progress
 Side effects
 Efficacy
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Women & Depression
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Women 2x likely to be
diagnosed, especially
younger women
Depression is
misdiagnosed 30 to 50
% of the time
70% of Rx’s given to
women, often without
proper monitoring
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Higher rates of
physical and sexual
abuse
Needs
– More Prevention
– More Research of
barriers to treatment
– More research on
differential risk
Depression and African
Americans
Higher risk due to SES
 Misdiagnosis
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Mistrust of medical system
Cultural barriers
Primary reliance on family and church
“Masked” by medical conditions, somatic
complaints or substance abuse
– SES limiting access to medical care
African American Attitudes
toward depression
(National Mental Health Association, 1996)
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63% (vs. 54%) “depression is a personal weakness”
Only 31% believed depression is a health problem
Only 20% said they would seek treatment
Only 25% connected change in eating habits or sleep with
depression; 16% irritability
Only 33% said they would take medication for depression
(vs. 69% of general population)
67% believed prayer & faith alone would successfully treat
depression “almost all of the time or some of the time.”
Depression and the Elderly
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Depression is NOT a normal part of aging, although 58%
of elders believe this
6 million affected, most women, < 10% tx’d
15% in community vs. 25% in ECFs
Often misinterpreted as medical condition
Elders with comorbid depression have 50% higher health
care costs; Depression is often secondary
40% experience reoccurrence
Only 38% believe it is a “health problem”
Only 42% would seek professional help
ECT efficacious
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Polypharmacy & Undermedication
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Suicide & the Elderly
Most at risk, 50% higher; 2/3 are due to
untreated depression
 20-25% of all suicides occur in the elderly
 EA men over 80 are 6x more likely
 Many have recently visited their PCP
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– 20% the same day
– 40% within one week
– 70% within one month
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Suicide
Incidence
History
Age/Gender/Race?
Marital Status
Life Stress
Psychiatric Disorders
• Parasuicidal behaviors
• Children & Adolescents
• Assessment & Prevention
• Contracts----Baker Act