DSM-IV Criteria For Major Depression ( > 5 for > 2 weeks)

2. 1. A 36-year-old female consults you at her mother’s urging for depressed mood, trouble sleeping, and decreased appetite for 3 weeks. She has no previous history of depression, but her mother is being treated successfully for depression. She is in a supportive marriage and is functioning well at work. She denies anhedonia, guilt, psychomotor retardation or agitation, trouble concentrating, decreased energy, and suicidal thoughts. Appropriate management options at this time include which of the following? (Mark all that are true) A. Sertraline (Zoloft) B. Paroxetine (Paxil) C. Cognitive-behavioral therapy D. Observation

3. Depressed mood Loss of interest or pleasure Appetite / weight change Insomnia / hypersomnia Psychomotor agitation / retardation Fatigue / loss of energy Worthlessness / excessive guilt Diminished ability to think / concentrate Recurrent thoughts of death / suicide DSM-IV Criteria For Major Depression( > 5 for > 2 weeks)

4. Minor / Subsyndromal Depression • No evidence for benefit of psychotherapy or medication • Close FU

5. 2. A 55-year-old male is showing signs of major depressive disorder after a myocardial infarction. True statements regarding this situation include which of the following? (Mark all that are true) Depression has been shown to be an etiologic factor in the development of ischemic heart disease The depression will most likely resolve as the patient recovers from the myocardial infarction Major depression is a significant predictor of short-term mortality from ischemic heart disease Major depression is a significant predictor of long-term mortality from ischemic heart disease Psychosocial interventions have been shown to be effective in improving depression in myocardial infarction survivors

6. Depression and Heart Disease

7. Depression and Heart Disease • Significant predictor of short-term AND long-term mortality • Medication and psychosocial interventions improve sx, ? impact on future events or mortality • Has not been shown to cause heart disease

8. In a patient diagnosed with major depression, which of the following would support the use of long-term maintenance antidepressant medication? (Mark all that are true.) Occurrence of the first episode during young adulthood Occurrence of the first episode at age 70 years or greater Occurrence of the first episode during adolescence Three lifetime recurrences A positive family history for depression in a first degree relative

10. Depression and Long-term Medical Therapy • > 2 recurrences in 5 years • > 3 recurrences lifetime • First occurrence > 70 years old

11. Which one of the following is true regarding perimenopausal depression? The loss of ovarian function during menopause is a major risk factor for the development of depression Hormone therapy has been shown to be an effective treatment for depression in perimenopausal women Life stress is a stronger predictor of depression during midlife than is menopause The incidence of depression in women peaks during the perimenopausal years

12. Perimenopausal Depression • Depression begins most commonly mid-twenties and thirties • Major predictors of depression in midlife • Hx depression • Life stress • General health • Data for estrogen mixed

13. 5. A 32-year-old female informs you that she and her husband have decided to have a child. She was diagnosed with major depression 3 months ago, but it has been well controlled with paroxetine (Paxil). She had a previous episode of major depression 10 years ago that also responded to paroxetine. She asks what effect antidepressant use would have on her pregnancy. Accurate advice would include which of the following? Pregnancy has been shown to have a salutary effect on major depressive disorder Paroxetine use during pregnancy has been linked to an increased risk of congenital heart malformations Paroxetine use in pregnancy has been linked to an increased risk for cleft palate SSRI use during the first trimester of pregnancy is associated with a higher risk of persistent pulmonary hypertension in the newborn Euthymic women who discontinue antidepressant therapy during pregnancy have a fivefold higher risk of relapse over the course of pregnancy compared with women who continue their antidepressant

14. Depression and PregnancyIssues • Risk of pregnancy loss • Teratogenesis • Neonatal toxicity / withdrawal syndrome after delivery • Long-term neurobehavioral effects on child

15. Depression and Pregnancy • 5x higher risk of relapse • Paroxetine 2005 Category D • Increased ASD, VSD • Increased R ventricular outflow obstruction • PPH with SSRI in late pregnancy

16. True statements regarding the prevalence and nature of depression in the elderly include which of the following? (Mark all that are true.) Depression is roughly two to three times more common in the elderly than in younger patients Physicians are more likely to correctly diagnose depression in elderly patients than in younger patients Treatment of depression in the elderly is less important than in younger patients because the depression is generally less severe Patients who are elderly when their first episode of depression occurs have a relatively high likelihood of developing chronic or recurring depression

17. “Take the green pill to feel hunky, the yellow pill to feel dory.”

18. Depression and Aging • Less common with aging • Not “normal” • Underdiagnosed, undertreated • Much higher risk chronicity / recurrence

19. Agents approved by the FDA for maintenance therapy in patients with bipolar disorder include which of the following? (Mark all that are true.) Lithium Divalproex (Depakote) Olanzapine (Zyprexa) Lamotrigine (Lamictal) Aripiprazole (Abilify) Bupropion (Wellbutrin)

20. Bipolar Disorder

21. Bipolar Disorder • Bipolar I • One or more manic or mixed episodes • Bipolar II • Hypomania and major depression • Cyclothymic • Numerous hypomanic and depressive episodes (not major depression)

22. Bipolar Disorder Chronic Treatment (FDA) (goal is sustained remission) • Lithium • Olanzapine (Zyprexa) • Lamotrigine (Lamictal) • Aripiprazole (Abilify)

23. A 33-year-old male presents with signs and symptoms of depression and a history of daily heavy alcohol and polysubstance abuse for the past 5 years. Which one of the following is true in this situation? Symptoms that resemble primary mood and anxiety disorders can result from alcohol and substance intoxication and withdrawal This patient has an organic mood disorder secondary to alcohol dependence Carbamazepine is the appropriate first-line medication to treat withdrawal symptoms in this patient Treatment for mood and anxiety disorders in patients with substance use disorders should be withheld pending a period of sobriety

24. Substance Abuse and Affective Disorders • Both disorders quite common • Association b/w the two significant • Likelihood of primary mood / anxiety disorders very high • Treatment for affective disorders should not be withheld pending sobriety / abstinence

25. 9. You are considering starting a program in which you screen all pregnant women for depression during their pregnancy and then immediately after delivery. Which of the following should be taken into account in such a program? (Mark all that are true.) The onset of postpartum depression frequently occurs before the patient is seen for a routine 6-week postpartum visit Screening questionnaires for depression during pregnancy have low sensitivity and high specificity The “baby blues” are so common during the first few weeks after delivery that screening for postpartum depression during that time would not be effective Significant dysphoria that arises more than 2 weeks after delivery should raise a strong suspicion for depression “Baby blues” commonly persist for several weeks after delivery

27. Post-Partum Depression • “Baby Blues” common but symptoms mild and transient • Persistent sx beyond 2 weeks or severe symptoms should raise suspicion • Incidence PPD up to 10 % • Questionnaires high sensitivity, low specificity

28. True statements regarding the relationship between depression and high utilization of medical care include which of the following? (Mark all that are true.) Depressed patients classified as high utilizers commonly present with defined medical conditions In patients classified as high utilizers, the incidence of current or past major depressive disorder is twice that of other patients The prevalence of defined medical conditions is higher among high utilizers who are classified as being depressed, compared to those who are classified as non-depressed Depressed patients classified as high utilizers have rates of medical resource utilization similar to those of nondepressed high utilizers

29. Depression and Utilization of Care • “High Utilizers” have high incidence (2x) of depression, often unrecognized • Depressed high utilizers more non-specific complaints • Depressed high utilizers higher resource utilization

30. A 32-year-old male who was successfully treated for major depressive disorder with paroxetine (Paxil) for the past 10 months chooses to stop his medication. Within a week he develops symptoms of dysphoria, fatigue, difficulty concentrating, anxiety, and insomnia. In addition, he also complains of an “electric shock” sensation in his legs and “rushing sensations” in his head. Which one of the following is the most likely diagnosis? Recurrence of major depressive disorder Dysthymic disorder SSRI discontinuation syndrome Bipolar disorder

31. SSRI Discontinuation Syndrome • Features Common with Depression • Dysphoria, Appetite/Sleep changes, fatigue, difficulty concentrating • Distinctive Features • Dizziness, Electric shock sensations face and extremities, HA, nausea, rushing sensation in head

32. SSRI Discontinuation Syndrome • Can start within 24 hours • Least common with • Fluoxetine (Prozac) • Most common with • Paroxetine (Paxil) • Sertraline (Zoloft)

33. A 28-year-old female with severe major depression has achieved partial symptom remission with SSRIs but complains of persistent diarrhea and loss of libido. She asks you about using St. John’s wort to treat her depression. Appropriate advice would include which of the following? (Mark all that are true) A. St. John’s wort may be effective in milder forms of major depression B. St. John’s wort is more effective than placebo in patients with severe major depression C. St. John’s wort is better tolerated than prescription antidepressants D. The combination of St. John’s wort and SSRIs is safe and effective for major depression E. St. John’s wort may reduce the efficacy of combined oral contraceptives

34. “The wise men brought gifts: ginseng, St. John’s wort, and ginko biloba.”

36. St. John’s wort • Species Hypericum perforatum (Tipton's or Klamath weed) • Challenge of standardization • Effective mild-moderate depression • Favorable SE profile • ? Increase risk of serotonin syndrome • May increase metabolism of ethinyl estradiol Cochrane 2008

37. 13. Patients in primary care settings may present with depressive symptoms that do not meet the full criteria for a DSM-IV Axis I depressive disorder. These symptom clusters are referred to as subsyndromal depressive symptoms. Which of the following statements apply to patients with these symptoms? (Mark all that are true) Subsyndromal depressive symptoms are less prevalent than full criteria DSM-IV Axis I mood and anxiety disorders in primary care settings The disability scale scores of patients with subsyndromal symptoms are equivalent to scores of patients with no psychiatric symptoms Psychotherapy is the most appropriate treatment modality for patients with subsyndromal depressive disorders Many patients with subsyndromal depressive symptoms also meet the criteria for other DSM-IV Axis I psychiatric disorders

38. Subsyndromal Depressive Symptoms • Challenging to define (? continuum) • Higher prevalence than major depression • Higher levels of impairment • Other Axis 1 psychiatric disorders common • Should have further screening / evaluation • Most effective treatment uncertain

39. 14. You diagnose postpartum depression in a 28-year-old woman 3 weeks after delivery. She is breastfeeding. When making decisions about her treatment, which of the following statements would be true? (Mark all that are true) SSRIs can be used safely, but only at a lower dosage and for a shorter length of time than is typical in women who are not breastfeeding Tricyclic antidepressants can cause anticholinergic effects in the breastfeeding newborn The greatest risk for behavioral or clinical side effects in the breastfeeding newborn whose mother is taking an antidepressant is at 3 or 4 months of age The risk-benefit decision regarding whether to use an antidepressant in a breastfeeding woman rests almost entirely on the severity of the depression and the need for medication, rather than on any known risks to the infant

41. Therapy for PPD • Medications have shown no specific behavioral or medical adverse effects • Should use usual doses for usual duration • TCAs can cause anticholinergic SE • Decision based on: • Severity • Patient desire • Potential harm in not treating

42. 15. Which one of the following is true regarding the effectiveness of antidepressants for treating major depression? SSRIs are the most effective class of antidepressants Tricyclic antidepressants (TCAs) are the most effective class of antidepressants Serotonin-noradrenalin reuptake inhibitors (SNRIs) such as venlafaxine are the most effective class of antidepressants Dopamine antagonists (DAs) such as bupropion (Wellbutrin) are the most effective class of antidepressants SSRIs, SNRIs, and DAs are more effective than TCAs All classes of antidepressants are equally effective

43. All Equally Effective “In reducing depressive symptoms and achieving remission of major depression” HOWEVER

44. STEPS S = Safety T = Tolerability E = Effectiveness P = Price S = Simplicity

45. The lifetime prevalence of major depressive disorder in the general population is 2%–5% 5%–10% 10%–20% 20%–30%

46. Definitions • Prevalence = The total number of cases of a disease in a given population at a specific time. • Incidence = The number of new cases within a specified time period divided by the size of the population initially at risk.

47. Prevalence of Depression • Lifetime major depression = 16.2% • One year prevalence = 5-7% (women 2x men) • Incidence data not well defined

48. You are treating a 53-year-old female for her first episode of major depression. After 6 weeks of treatment with antidepressants, all depressive symptoms have resolved. Evidence suggests that the TOTAL length of treatment with antidepressants for this patient should be AT LEAST 3 months 6 months 12 months 18 months

49. Duration of Treatment • “Early discontinuation” associated with early relapse • Data suggest at least 6 months, though continued benefit in preventing relapse found out to 3 years • ? Implications with severity of depression (mild through severe)

50. True statements regarding dysthymic disorder include which of the following? (Mark all that are true) Dysthymic disorder is less prevalent than major depressive disorder in primary care settings Psychiatric comorbidity is uncommon in patients with dysthymic disorder Dysthymic disorder is less likely than major depressive disorder to lead to significant functional impairment Dysthymic disorder usually results from the stress of chronic medical conditions