Depression The Demon Within

1. DepressionThe Demon Within Mikal Burley PA-S OHSU School of medicine Physician Assistant Program

2. Depression Fact? Depression is more common in women than men and is especially common during the teen years. True or False….WHY….? True…Men seem to seek help for feelings of depression less often than women. Therefore, women may only have more documented cases of depression.

3. Learning Objectives Define depression Recognize 4 key signs of depression Identify 3 risk factors for depression List 3 things you can do to help prevent depression Know where to get help if you, or someone you know, is depressed

4. Definition of Depression • Depressed mood, loss of interest or pleasure on a daily basis for at least 2 weeks. Includes: • Sadness • Indifference • Apathy • Irritability Longo DL, Fauci AS, Kasper DL, et al. Harrison’s Principles of Internal Medicine. 18th ed. San Francisco, CA: McGraw Hill; 2012: 3536.

5. Definition of Depression “Depression is related to the normal emotions of sadness and bereavement, but it does not remit when the external cause of these emotions dissipates” - RH Belmaker, MD Belmaker RH, Agam G. Major Depressive Disorder. N Engl J Med. 2008; 358: 55-68.

6. True Clinical Depression …is a mood disorder when theses feelings interfere with everyday life for an extended period of time. Ranked in severity- Mild, Moderate, Severe. This determines the treatment.

7. Types of Depression Major Depressive Disorder (MDD) Dysthymic disorder Seasonal Affective Disorder (SAD) Bipolar disorder Normal Sadness and Moodiness Severe Depression (MDD) Dysthymia

8. Why Does it Matter? Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and Ongoing Management. Pediatrics. 2007; 120 (5): 1313-1326. Major Depressive Disorder in Children. NIMH. http://www.nimh.nih.gov/statistics/1MDD_CHILD.shtml. Accessed October 21, 2012. National Statistics 9% of teenagers meet criteria for depression at any one time 1 in 5 (20%) teens will have depression at some point during adolescence Only 50% of adolescents are diagnosed before they reach adulthood.

9. Why Does it Matter? Oregon Statistics: 11th Graders 25% reported depression within the last year 12.5% seriously considered suicide Oregon Health Authority. Oregon Healthy Teens 2011 11th Grade Results. http://www.public.health.oregon.gov. Accessed Nov 18th, 2012.

10. Why Does it Matter? Risks Include Increased physical illness Substance abuse Decline in school performance Poor social functioning Early pregnancy USPSTF. Screening and Treatment for Major Depressive Disorder in Children and Adolescents: USPSTF Recommendation Statement. Pediatrics; 123 (4): 1223-1228.

11. Why Does it Matter? USPSTF. Screening and Treatment for Major Depressive Disorder in Children and Adolescents: USPSTF Recommendation Statement. Pediatrics; 123 (4): 1223-1228. Increased risk of suicide • 3rdleading cause of death among those aged 15 to 24 • 4-5% suicide rate among depressed people “A fallen angel”

12. Recognizing Depression • Low mood and diminished interest or pleasure PLUS • Weight gain or loss • Appetite changes • Sleep disturbances • Fatigue/ loss of energy • Feelings of worthlessness • Excessive or inappropriate guilt • Social isolation • Slowed speech or movements OR agitation • Difficulty thinking or concentrating • Decline in schoolwork • Indecisiveness • Recurrent thoughts of death or suicide Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 2000.

13. Recognizing Suicidal Behavior • Warning signs: • Giving away treasured possessions • Saying things like: • “I’d be better off dead.” • People will love me more after I’m gone.” • Writing stories or poems about death and dying • Saying goodbye as if for good

14. What Causes Depression? • Depression Handout. NIMH. NIH Publication No. 11-3561. Revised 2011.

15. What Causes Depression? • Disorder of the brain • Neurochemical dysfunction • Multiple hypotheses • Neurotransmitter deficiency • Stress hormones • Abnormal circadian rhythms • Etc., etc… Belmaker RH, Agam G. Major Depressive Disorder. N Engl J Med. 2008; 358: 55-68.

16. How is Depression Treated? • Antidepressant medications • Selective Serotonin Reuptake Inhibitors (SSRI) • Tricyclics • Monoamine Oxidase Inhibitors (MAOI) • Psychotherapy • Cognitive behavioral therapy • Interpersonal therapy • Lifestyle Change • Regular exercise • Healthy diet • Stress management

17. How Do I Help a Friend or Loved One? • Offer emotional support and encouragement • Provide assistance in getting to doctor’s appointments – diagnosis and treatment is key! • Invite your friend to join in on fun activities • Never ignore comments about suicide • Tell a responsible adult or your friend’s doctor or therapist • Remind them that with time and treatment, the depression will lift Depression Handout. NIMH. NIH Publication No. 11-3561. Revised 2011.

18. What If I Am Depressed? Confide in a trusted friend or relative Seek help from a medical provider – do not wait Try to stay active, exercise and spend time with others – don’t isolate yourself Try to maintain a healthy diet and good sleep habits Remind yourself that with treatment and time, you will feel better

19. Where Do I Get Help? Parents Teachers School counselors Friends Your family doctor, PA or NP

20. Prevention Self Harm and Suicide? • Do not leave a suicidal friend or relative alone • Talk to someone • Call your doctor, call 911 or go to the ER • National Suicide Prevention Lifeline • Toll free, 24 hours • 1-800-273-TALK (1-800-273-8255)

21. Suicide Prevention Allow the person to share their feelings Stress the temporary nature of their problems Make clear that you understand their problems but that suicide is not the answer Don't leave them alone if threat is immediate Suggest that they speak to a trusted adult about their problems Do Not agree to keep it a secret!

22. Know the signs, Know what to do… In summary… http://www.youtube.com/watch?v=CHynDpYv1Gw&feature=player_detailpage

23. Questions? Advice Letter …on back of note handout

24. Handling Emotions: Writing Assignment (ADVICE LETTER) • On a Blank sheet of paper write a letter to an Advice Columnist about a real or imagined situation involving strong emotions, • Emotions could include: jealousy, fear, anger, depression, sadness, guilt, or love. • These emotions could be your own or from a close friend or family member. • Real names should not be used. Make one up. .Ex: " Down in the Dumps Davita". Be Creative! • In your letter you will need to describe/explain the difficulty with handling the situation and feelings being felt. • Ask for advice on what to do? • This should be about 7-10 sentences long. 2 paragraphs in length (example on back).

25. Example: Dear Abby: I’m 18 years old. I play two competitive sports, maintain a 4.0 GPA, have good friends and will be attending the college of my dreams. Yet for some reason I cannot get along with my parents. It seems like I can’t live up to their standards. We get into huge fights every day over insignificant things. My parents continually tell me they don’t think I will handle college very well because I “can’t get along with people.” But their lack of faith just frustrates me and we get into more fights. In reality, the only people I don’t get along with are my parents. This is unsettling to me because next fall I will be across the country from them and I feel they will be happy that I’m gone. I’m at a loss as to what to do to control my temper and fix my relationship with my parents before I leave. Your advice would be appreciated. …Climbing The Walls In Cleveland

26. Dear Climbing The Walls: It’s possible that your parents may be suffering from separation anxiety. You, their child, are about to leave the nest, and they may be dealing with conflicting feelings of pride in your accomplishments and sadness that you are about to fly from the nest. It may not be a lack of faith in you. Also, they may be having second thoughts about how they can afford the tuition and other college expenses beyond possible financial aid. Whatever their reasons are, you need some tools to help you stay calm and not fly off the handle when your buttons are pushed and suggestions that will help you gain control of your emotions so that you will lose your temper less often. Anger is a normal emotion. There are probably no human beings who don’t experience anger at one time or another. However, it’s important that you learn some techniques to handle your emotional reactions more constructively than you have been. Not only will these techniques help you with your parents now, but also they will help you when you’re away at college adjusting to new people and new situations. Remember, the average person may become irritated frequently. The key is to deal with these emotions effectively. Talk to your parents about your feelings and explore what’s going on. By focusing on what is triggering your negative emotions instead of reacting with an outburst, you can not only defuse your anger but also retain your dignity, and possibly achieve a more informed understanding of how your parents may really feel. Signed: (your real name)

27. References Longo DL, Fauci AS, Kasper DL, et al. Harrison’s Principles of Internal Medicine. 18th ed. San Francisco, CA: McGraw Hill; 2012: 3536. Belmaker RH, Agam G. Major Depressive Disorder. N Engl J Med. 2008; 358: 55-68. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 2000. Zuckerbrot RA, Cheung AH, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, Assessment, and Initial Management. Pediatrics. 2007; 120 (5): 1299-1312. Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and Ongoing Management. Pediatrics. 2007; 120 (5): 1313-1326. Major Depressive Disorder in Children. NIMH. http://www.nimh.nih.gov/statistics/1MDD_CHILD.shtml. Accessed October 21, 2012. USPSTF. Screening and Treatment for Major Depressive Disorder in Children and Adolescents: USPSTF Recommendation Statement. Pediatrics; 123 (4): 1223-1228. Depression Handout. NIMH. NIH Publication No. 11-3561. Revised 2011. Oregon Health Authority. Oregon Healthy Teens 2011 11th Grade Results. http://www.public.health.oregon.gov. Accessed Nov 18th, 2012.