Transcript Depressive Disorders

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Depression and Anxiety Disorders
Basic Pathophysiology
Depression and anxiety are among the most common disorders seen in
medical practice.
The pathophysiology and etiology of these illnesses are diverse and complex.
A combination of environmental factors and genetic predispositions is
believed to contribute to both anxiety and depressive disorders. Traumatic or
stressful life events can also trigger episodes.
It is common for someone with an anxiety disorder to also suffer from
depression and vice versa.
Altered levels of neurotransmitters (including norepinephrine , serotonin,
dopamine, and gamma-aminobutyric acid [GABA]) have long been implicated
and are the primary target of pharmaceutical treatments for both conditions.
However, it is not clear if neurotransmitter imbalances are a fundamental
cause or instead a consequence of these conditions.
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Depression and Anxiety Disorders
Basic Pathophysiology
Just as depression and anxiety are associated with increased risk of chronic
diseases, numerous chronic diseases increase the risk of depression or anxiety
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Clinical and epidemiological studies suggest that physical inactivity may even
be associated with the development of a variety of mental disorders, including
depression and anxiety.
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Depressive Disorders
• Major depressive disorder (Video)
• Bipolar disorder ( Video )
• Disruptive mood dysregulation disorder [DMDD] (for minors
<18 years of age)
• Persistent depressive disorder (formerly called dysthymia)
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Basic Pathophysiology
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Major Depressive Disorder (MDD)
• Also known as clinical or major depression, major depressive disorder
(MDD)
• Leading cause of disability among adults in the United States and
throughout the world.
Diagnosis of MDD is characterized by at least five of the following
symptoms, occurring on most days, for at least two weeks.
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Basic Pathophysiology
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Bipolar Disorder
• Also referred to as manic–depressive illness, bipolar disorder causes
atypical shifts in mood, energy, and behavior.
• Extreme euphoria, hyperactivity, and impulsivity may accompany
a manic episode, whereas intense sadness and a feeling of hopelessness
characterize a depressive episode.
• These cycles of mood state may last anywhere from a few days to several
months and correspond to extreme changes in energy, activity, sleep,
and behavior.
• Between episodes, people may be symptom free, but episodes of mania
and depression typically come back over time.
Some minors (under the age of 18) have symptoms consistent with bipolar
disorder, and under DSM V these have been reclassified as disruptive
mood dysregulation disorder (DMDD)
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Basic Pathophysiology
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Persistent Depressive Disorder
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• Persistent depressive disorder (PDD, formerly known as dysthymia) is a
chronic type of depression characterized by a consistently low mood,
though symptoms are not as severe as with MDD.
• People present with many of the same symptoms as with MDD: low
energy, sleep disturbances, changes in appetite, etc.,.
• Individuals may be more irritable, stress easily, or experience anhedonia,
which is the inability to derive pleasure from activities once found
enjoyable.
• There is no clear factor differentiating the disorder from MDD other than
intensity or severity of symptoms, but the clinical impact of this change
remains to be seen. PDD is common in people with chronic conditions.
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Basic Pathophysiology
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Anxiety Disorders - (General Overview – Video)
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Anxiety disorders encompass a group of illnesses that include social
phobias, panic disorder, obsessive–compulsive disorder (OCD), (Video)
posttraumatic stress disorder (PTSD), and generalized anxiety disorder
(GAD). (VIDEO )
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There is considerable individual variability in both the severity and type of
symptoms exhibited with these conditions. Symptoms typically include
excessive worry, apprehension, fear, and uneasiness, and physiological
symptoms of heightened (fight-or-flight response):
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Anxiety Disorders
Symptoms of Anxiety
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Chronic stimulation of the physiological stress response exacerbates and even
causes chronic conditions such as cardiovascular disease, immunosuppression,
and MDD.
Depression and Anxiety Disorders
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Management and Medications
Treatments for depression and anxiety are diverse and have varying degrees of
effectiveness.
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Management traditionally consists of pharmacological intervention, cognitive
behavioral therapy, dialectical behavior therapy, or a combination of
pharmacological and behavioral therapies.
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Treatment for depression can help not only manage symptoms but also prevent
recurrence.
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Antidepressants
Most classes of antidepressants work by changing the level of one or more
neurotransmitters in the brain, mostly serotonin and norepinephrine.
By blocking their absorption (reuptake) from the synaptic cleft—the space
between neural cell synapses—more of the transmitter is available for
stimulation.
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Depression and Anxiety Disorders
Management and Medications
Listing of Antidepressant Medications - FYI
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Depression and Anxiety Disorders
Management and Medications
Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is typically used for people with severe MDD
who are unresponsive to all other antidepressant treatments, may be at
high risk of suicide, or may not be able to take pharmaceuticals for health
reasons or pregnancy.
The mechanisms of action are unclear, but the electric currents that pass
through the brain are hypothesized to reduce depressive symptoms by
affecting neurotransmitter levels.
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Mood Stabilizers
Bipolar disorder can be difficult to manage and is commonly treated with
mood-stabilizing drugs. Lithium is usually one of the first medicines
prescribed for bipolar disorder.
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Depression and Anxiety Disorders
Management and Medications
Anxiety Disorders
• First Line - Most selective serotonin reuptake inhibitor (SSRI) and
selective serotonin–norepinephrine reuptake inhibitor (SNRI)
antidepressants also have anxiolytic properties.
• Second Line - Benzodiazepines are the other main anxiolytic class of
medications and are believed to diminish neural hyperactivity by
increasing the inhibitory neurotransmitter gamma-aminobutyric acid
(GABA).
• Benzodiazepines have more side effects than SSRIs or SNRIs
and thus are usually second-line agents
• Common side effects are related to the sedating and musclerelaxing action of these drugs: drowsiness, dizziness, and
decreased alertness and concentration. Such side effects may
impair coordination and increase risk of falls and injuries,
especially in persons who are elderly or frail.
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Depression and Anxiety Disorders
Management and Medications - FYI
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Exercise also appears to be an effective alternative treatment for certain
anxiety disorders. However, exercise alone does not reduce anxiety to the
same extent as pharmaceuticals.
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Depression and Anxiety Disorders
Effects on the Exercise Response
Depression and anxiety disorders do not typically alter physiological changes to
exercise.
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However, psychomotor retardation, most commonly seen with depression, can
cause a visible slowing of motor movements and reaction times. This may be
exacerbated with anxiolytic medications.
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Other concurrent pharmacological interventions may affect the exercise
response. Thus, gathering a thorough medical history and listing of current
medications is important.
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Several drug classes used for treatment in these populations may reduce
functional aerobic capacity, affect perception and coordination, or reduce the
desire to be physically active
Depression and Anxiety Disorders
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Effects of Exercise Training
The efficacy of exercise compares favorably with that of antidepressant
medications for mild to moderate depression, and depressive symptoms are
further improved when exercise is used as an adjunct treatment to
antidepressant medications.
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The psychological and physical benefits of exercise can help reduce anxiety and
alleviate symptoms of depression.
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Depression
• Exercise and physical activity are effective in significantly reducing
symptoms of depression, and regular aerobic exercise is equal in
effectiveness to some pharmacotherapy treatments in mild to moderate
depression.
• Relapse of depression is less likely with exercise as compared to
antidepressant treatment
• As an adjunct to antidepressant medicines, exercise appears to further
improve symptoms compared to medication alone.
Depression and Anxiety Disorders
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Effects of Exercise Training
Depression
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The mechanisms underlying exercise-related improvements in depression are
not known. Proposed psychological factors include :
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increased self-efficacy,
gaining a sense of mastery,
distraction from negative thoughts, and
enhanced self-concept.
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Exercise-related improvements in sleep quality and the circadian sleep cycle
may also reduce symptoms.
Depression and Anxiety Disorders
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Effects of Exercise Training
Anxiety
Exercise training significantly reduces symptoms of anxiety when compared
to no treatment or cognitive behavioral therapy.
Unlike the situation with depression, exercise alone does not appear to
reduce anxiety to the same extent as pharmaceuticals.
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Recommendations for Exercise Testing
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Exercise testing recommendations for people with depressive or anxiety
disorders depend on the impact of the condition on the patient’s daily
functioning:
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High functioning without comorbid conditions: follow the ACSM
Guidelines.
• Low functioning due to comorbid conditions: use the Basic CDD4
Recommendations
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Depression and Anxiety Disorders
Recommendations for Exercise Programming
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Just as with the recommendations for exercise testing, the recommendations
for exercise programming when working with people who have depressive
and anxiety disorders depend on the individual’s level of functioning:
• High functioning without comorbid conditions: follow the ACSM
Guidelines.
• Low functioning due to comorbid conditions: use the Basic CDD4
Recommendations.
People should be encouraged to achieve at least the minimum
recommended levels of 150 min/week or more of moderate-intensity
physical activity.
For mild to moderate depression, total energy expenditure appears to be a
key consideration, with activity levels below 150 min/week having no
significant effect.
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