Depressive Disorders and Substance Use Disorders

1. Depressive DisordersandSubstance Use Disorders

2. Major Depressive Disorder • Major depression is a treatable disorder • Major depression has a significant morbidity (prevalence) and a notable mortality rate (leading to death) • Major depression is one of a number of different mood disorders

3. Major Depressive Disorder • Presence of one (Single Episode) or more (Recurrent) Major Depressive Episodes • Not better accounted for by a Schizoaffective or other type of disorder • Not accompanied by any episodes of mania

4. Depressive Episode • Five or more of the following are present during the same 2-week period, and represent a change from previous functioning, and at least one of the symptoms is either (1) depressed mood, or (2) loss of interest . . .

5. Depressive Episode • Depressed mood most of the day, every day • Loss of interest or pleasure in most all activities, every day • Significant weight loss w/o dieting • Insomnia / hypersomnia every day • Psychomotor agitation / retardation every day • Fatigue or energy loss every day • Worthlessness or inappropriate guilt feelings nearly every day • Decreased ability to think, concentrate or make decisions nearly every day • Recurrent thoughts of death, or suicidal ideation, with or without plan &/or attempt

6. Depressive Episode • Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

7. Depressive Episode • Symptoms are NOT due to the effects of a substance(e.g., drug of abuse, or medication) or a general medical condition (e.g., hyperthyroidism)

8. Depressive Episode • Symptoms are not better accounted for by Bereavement (i.e. lasting longer than 2 months after a significant loss, or characterized by severe degree of functional impairment, preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation)

9. Prevalence • The National Comorbidity Survey found: For any mood disorder • Life time prevalence was 19.3% • Annual prevalence was 11.3% For Major Depressive Episode • Life time prevalence was 17.1% • Annual prevalence was 10.3% Female to male ratio is 2:1

10. A Spectrum of Depression • Some of the types of depressive disorders include Dysthymic Disorder Major Depressive Disorder “clinical depression” Post Partum Depression Seasonal Affective Disorder Mood disorder secondary to a medical condition Substance induced mood disorder Other mood disorders can include depressive episodes, such as Bipolar disorder

11. Gender differences • The lifetime prevalence rate of major depression is estimated at between 5 to 12% for men between 10 to 25% for women

12. Age • Depression can happen at any age • Teenagers can have depression -adolescent rate is between 3 and 8% -teen depression is estimated to be 6x more likely when a parent also has depression -signs/symptoms can be masked “irritable moodiness” -suicide is the 3rd leading cause of death for 15-25 year olds

13. Co-Occurring Medical Conditions • Nearly 70% of all anti depressant medication prescriptions are written by primary care doctors • Certain medical disorders are associated with higher-than-expected rates of depression Stroke Neurodegenerative disorders HIV/AIDS Endocrine disorders Diabetes

14. What isn’t depression? • “The blues” – temporary • Normal grief – situational • Depression is an illness, while “the blues” are normal reactions to life situations. • Symptoms of depression include multiple moods, thoughts, and bodily functions whereas the blues is composed of a single state of being in a low mood • Depression may persist for months, years, decades

15. Dysthymic Disorder • Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years, but without a major depressive episode occurring.

16. Dysthymic Disorder • Dysthymic depression has 2 or more of the following: • Poor appetite, or overeating • Insomnia or hypersomnia • Low energy or fatigue • Low self-esteem • Poor concentration or difficulty making decisions • Feelings of hopelessness

17. Other forms of depression • Postpartum Depression A condition which describes a range of physical and emotional changes a woman may have after having a baby. Most partum depression can range from a mild degree to severe with psychotic features (postpartum psychosis). This is not the “baby blues”. -happens from several days to several months post childbirth -higher level of intensity -interferes with functioning

18. Postpartum Depression Symptoms include: • Restlessness • Irritability • Feeling sad • Crying a lot • Lack of energy • Headaches • Chest pains, heart palpitations • Difficulty sleeping and/or eating • Trouble concentrating • Sense of being overly worried about baby • Not having any interest in the child • Feelings of worthlessness, guilt • Fear of harming self or child

19. Seasonal Affective Disorder It is noticed that animals react to the changing seasons in mood & behavior and human beings are no exception. Most people have a tendency to eat and sleep a little more in the winter and dislike the dark mornings and short days. For some, it seems to have a more intense effect in disrupting their lives and causing significant distress. Symptoms include: Change in appetite, weight gain, “heavy feeling” in arms/legs, drop in energy level, fatigue, oversleeping, difficulty concentrating, irritability, increase sensitivity to others, avoidance of social situations. • Estimated 10-20% may experience some mild form of SAD, more common in women • Usually starts after age 20 • More common in northern geographic regions, September – April There’s an association with lack of bright light- bright light makes a difference to the brain chemistry although they are not sure by what means the sufferers are affected. Treatment includes natural light, light box/full spectrum light, behavioral therapy, medication when necessary.

20. What about Depression & Substance Use? • For discussion: Why would someone with depression use substances? What is the risk of using substances when there is a co-occurring depressive disorder?

21. Dual Diagnosis Issues • Certain intoxication syndromes(usually with depressant substances) &/or withdrawal syndromes(usually from stimulants) can mimic some of the symptoms of a depressive episode, thus making accurate diagnosis and effective treatment more complicated. • Exs. Sedative intoxication, Cocaine withdrawal

22. Sedative Intoxication • Inappropriate sexual or aggressive behavior • Slurred speech • Stupor • Impaired attention or memory • Mood lability • Impaired judgment • Psychomotor retardation or agitation • Impaired social, occupational, or other functioning

23. Cocaine Withdrawal • Depressed mood • Fatigue • Vivid, unpleasant dreams • Insomnia or hypersomnia • Increased appetite • Psychomotor retardation or agitation • Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

24. Sedative Intoxication • Inappropriate sexual or aggressive behavior • Slurred speech • Stupor • Impaired attention or memory • Mood lability • Impaired judgment • Psychomotor retardation or agitation • Impaired social, occupational, or other functioning

25. Cocaine Withdrawal • Depressed mood • Fatigue • Vivid, unpleasant dreams • Insomnia or hypersomnia • Increased appetite • Psychomotor retardation or agitation • Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

26. Why does depression happen? • Emerging data supports that • stress • genetic predisposition • differences in brain chemistry & brain structures • life experiences Interact to cause depression.

27. Genetic Factors First degree relatives of depressed individuals have a higher rate of depression.

28. Brain Structures • Post-mortem receptor studies in depressed suicide victims show differences in the hippocampus, hypothalamus, and prefrontal cortex. • Neruo imaging studies shows impaired regulation of serotonergic activity.

29. Life Experiences • Abnormal stress at critical development periods may have long lasting effects on the CNS development. Emerging evidence indicates that individuals with depression are more likely (than controls) to have a history of childhood abuse, deprivation, or abandonment

30. Suicide Awareness • The vast majority of people who SEEK treatment have success in alleviating symptoms. • Not everyone who has depression becomes suicidal, but over 90% of those who die of suicide have a diagnosable mental illness Warning signs include: • Talking about suicide. • Statements about hopelessness, helplessness, or worthlessness. • Preoccupation with death. • Suddenly happier, calmer. • Loss of interest in things one cares about. • Visiting or calling people one cares about. • Making arrangements; setting one's affairs in order. • Giving things away.

31. Seek Help! • Community Crisis Response Team (CCRT) 734-994-8048 (24/7) • Psychiatric Emergency Services 734-936-5900 (24/7) • CSTS or other mental health providers • Hotlines 1-800-SUI-CIDE 1-800-273-TALK • For every 25 attempts there is 1 death. Take attempts seriously. Seek help!

32. Treatment options • “Multi modal” • Anti depressant medication • Psychotherapy • Behavior/lifestyle: exercise, nutrition, sleep • light therapy • ECT

33. Principles of Dual Recovery • Treatment of both mental illness and substance abuse at the same time • Individualized dual recovery plan • Collaboration and coordination • Keeping hope alive

34. Principles of Dual Recovery • Medication adherence • Dual diagnosis &/or other treatment groups • Self-help groups (DRA, DBSA, AA, NA), other support networks • Family support and problem solving • Individual therapy • Motivational strategies

35. Principles of Dual Recovery • Managing stressors, triggers, relapse risk factors • Skill-building in areas of need • Increased overall structure and lifestyle balance (including proper diet, exercise, sleep habits)

36. Any Questions or comments?

37. Thank you for coming!