Depression and Seasonal Affective Disorder

1. Depression and Seasonal Affective Disorder Lisa L. Willett, MD December 11, 2007 Common Ambulatory Topics Seminar General Medicine Noon Conference

2. Why do I care? Prevalent Unrecognized depression seeks medical attention more often (physician, cost) Fourth leading cause of disability Second only to heart disease Marked suffering, increased mortality Treatment is effective

3. Case 47 yoF complains of fatigue Irritable, short tempered No energy, wants to sleep all day Stressed Shopping, decorating, cooking, cleaning Works full time, 4 kids, lazy husband Family strife (in-laws are coming to visit)

4. Common Clinical Questions Does she have major depression most important screening questions Does she have seasonal affective disorder Does she require medications Is she at risk for suicide

5. DSM-4 CriteriaMajor Depression (>5, >2weeks) Depressed mood Anhedonia Sleep disturbance Appetite or weight change Fatigue or loss of energy Psychomotor activity Decreased concentration Guilt or worthlessness Suicidal ideation

6. Depressed Mood How is your mood? Do you ever feel down or depressed or blue? How often does it happen? How long does it last? Most of the day, nearly every day

7. Anhedonia What do you do for fun? Have you lost interest in your usual activities? Do you get less pleasure in things you used to enjoy? Diminished pleasure in almost all activities most of the day, nearly every day

8. Screening Instruments Multiple questionnaires, from 1-30 items Administration time < 1 to 5 minutes Patient Health Questionnaire (PHQ)-9, -2 Short Form General Health Survey (SF-20) Variable performance, overall similar Consider time, desire to screen for other psychiatric illnesses, monitor responses

10. Seasonal Affective Disorder Definition: the seasonal pattern of major depressive episodes Recurring depression with seasonal onset Full remission 2 patterns Summer-onset � typical depression symptoms Fall-onset (�winter depression�) - atypical

11. Seasonal Affective Disorder Data very limited More common in young women, age 23 Decreasing daylight, abnormal melatonin? Longer, more severe with higher latitudes Responds to light therapy Associated with alcohol, ADHD, anxiety/panic Decreased central serotonergic activity HTR2A gene (codes for serotonin receptor)

12. Clinical Features: Fall onset Atypical depression symptoms Increased sleep Increased appetite Irritability Markedly increased weight Interpersonal difficulties (rejection sensitivity) Leaden paralysis heavy, lead in arms/legs

13. Therapy Light therapy Cognitive behavioral therapy Pharmacotherapy

14. Light Therapy

15. Cognitive behavioral therapy

16. Pharmacotherapy: Indications Prior positive response to antidepressants High suicide risk Significant functional impairment Moderate to severe recurrent depression Patient preference Failed light therapy or psychotherapy

17. Drugs Treatment Fluoxetine (Prozac) Sertraline (Zoloft) Prevention Wellbutrin XL (bupropion HCL extended-release tablets) Depression free at end of treatment 84% vs. 72% placebo

18. Does she have seasonal affective disorder?

19. Case 47 yoF complains of fatigue Irritable, short tempered No energy, wants to sleep all day Stressed Shopping, decorating, cooking, cleaning Works full time, 4 kids, lazy husband Family strife (in-laws are coming to visit)

20. Major Depression (>5, >2weeks) Depressed mood Anhedonia Sleep disturbance Appetite or weight change Fatigue or loss of energy Psychomotor activity Decreased concentration Guilt or worthlessness Suicidal ideation

21. Case, cont Major Depression? Feel down, don�t enjoy the season anymore for about 3 weeks Tired, I want to sleep all day Fatigued, no energy Stressed Eat more, gain weight Quit exercising

22. Major Depression (>5, >2weeks) Depressed mood Anhedonia Sleep disturbance Appetite or weight change Fatigue or loss of energy Psychomotor activity Decreased concentration Guilt or worthlessness Suicidal ideation

23. Case 47 yoF complains of fatigue Irritable, short tempered No energy, wants to sleep all day Stressed Shopping, decorating, cooking, cleaning Works full time, 4 kids, lazy husband Family strife (in-laws are coming to visit)

24. Clinical Features: Fall onset Atypical depression symptoms Increased, not decreased, sleep Increased, not decreased, appetite Markedly increased weight Irritability Interpersonal difficulties (rejection sensitivity) Leaden paralysis (heavy, lead in arms/legs)

25. How would you treat her?Does she require medications?

26. Therapy Light therapy Cognitive behavioral therapy Pharmacotherapy SSRI: Fluoxetine (Prozac) ,Sertraline (Zoloft) Prevention next year (buproprion) Don�t forget bipolar disorder Don�t forget to ask about suicide

28. Suicide Patients rarely volunteer - ask directly Major risks: prior suicide attempts, family history of suicide substance abuse physical illness (HIV, cancer, asthma) poor functional capacity, hopelessness pyschiatric history sociodemographics

29. Who is at most risk? Despite medical illnesses, suicide is most often related to unrecognized co-morbid psychiatric illness Most often depression Sociodemographics Social isolation Age over 60 Male White or Native American

30. Screening Questions �Have you been feeling that life is not worth living or that you would be better off dead?� �Sometimes when a person feels down or depressed, they might think about dying. Have you been having any thoughts like that?�

31. If yes� �Do you have a plan?� Ask if materials assembled, time set, factors that may precipitate or prevent patient from carrying out Urgent/emergent psychiatry evaluation SSRIs � controversy of increased attempts Evidence does not support withholding treatment

32. Common Clinical Questions Does she have major depression most important screening questions Does she have seasonal affective disorder Does she require medications Is she at risk for suicide