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Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
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Depression

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As part of an early Educational Grand Round, Peter Brengel, MPAS, PA-C, MBA gives his talk about Depression. …

As part of an early Educational Grand Round, Peter Brengel, MPAS, PA-C, MBA gives his talk about Depression.

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  • 1. DEPRESSION and its possible causes a S’eclairer teaching topic June 2013 7/22/2013 1
  • 2. DEPRESSION and its possible causes ◦ A Personal experience ◦ DSM V criteria ◦ Sherwin Nuland video ◦ World Health Organization Study ◦ What Causes Depression? -Monoamine hypothesis -Glutamate hypothesis -Systemic hypothesis -Trauma 7/22/2013 2
  • 3. PERSONAL EXPERIENCE 7/22/2013 3
  • 4. DSM V DEFINITIONS  Major Depression (MDD) Five or more of the following for 2 weeks or more: -depressed mood -anhedonia (loss of interest or pleasure) -weight gain/loss -insomnia/hypersomnia -loss of energy -feelings of worthlessness/guilt -loss of concentration/decisiveness -thoughts of death/suicide -psychomotor agitation 7/22/2013 4
  • 5. Sherwin Nuland presentation  Prominent surgeon at Yale-New Haven hospital  Major breakdown at age 42  Presentation on the west coast in 2001 7/22/2013 5
  • 6. NULAND PRESENTATION http://embed.ted.com/talks/sherwin_nul and_on_electroshock_therapy.html 7/22/2013 6
  • 7. WHAT IS THE IMPACT OF DEPRESSION? WORLD HEALTH ORGANIZATION Global Burden of Disease Leading Causes of Disability 2004 Survey Unit of measurement= DALY (Disability Associated Life Year) 7/22/2013 7
  • 8. 2004 2030  Lower respiratory infections  Diarrheal diseases  Unipolar depression  Unipolar depression  Ischemic heart disease  Traffic accidents WORLD HEALTH ORGANIZATION Global Burden of Disease Leading Causes of Disability 7/22/2013 8
  • 9. What causes depression?  Monoamine hypothesis  Glutamate hypothesis  Systemic hypothesis  Trauma 7/22/2013 9
  • 10. Monoamine hypothesis- not enough:  Serotonin  Norepinephrine  Dopamine 7/22/2013 10
  • 11. Glutamatergic hypothesis:  Too much glutamate at the NMDA receptor  Resulting in too much excitation in the prefrontal cortex of the brain 7/22/2013 11
  • 12. LIKELY SEQUENCE OF TREATMENTS:  SSRIs (Prozac, Zoloft)  SNRIs (Cymbalta)  Atypical antidepressants (bupropion/Wellbutrin)  Antiepileptics for mood control (valproic acid, carbamazepine)  “cocktail” of foregoing  Psychotherapy concurrently  ECT  Ketamine 7/22/2013 12
  • 13. ECT TREATMENT 1973 CASE:  “tangle of twisted wires in my head”  NIH: ECT seizures cause discharge of neurotransmitters HISTORY:  Discovered in 1938 in Rome  Precise mechanism unknown  Efficacy studies vary widely CURRENT PRACTICE:  Sedation plus muscle relaxant  Pulsed was continuous  6 to 10 treatments over 2 to 3 weeks  Bitemporal, unilateral, bifrontal  Reported memory loss 7/22/2013 13
  • 14. GLUTAMATE RECEPTORS  IONOTROPIC: (ion channels) -NMDA (N-methyl-D-aspartate) -AMPA -Kainate  METABOTROPIC: (G-protein-coupled) 7/22/2013 14
  • 15. GLUTAMATERGIC SYSTEMSource: Machado-Vieira R & Zarate CA Proof of Concept Trials in Bipolar Disorder and Major Depressive Disorder: A Translational Perspective in the Search for Improved Treatments Published online 24 February 2011 in Wiley Online Library 7/22/2013 15
  • 16. SYSTEMIC HYPOTHESIS Bodily disorders destabilize the brain  Systemic inflammation  Vitamin/mineral deficiencies  Heavy metals toxicity 7/22/2013 16
  • 17. SYSTEMIC INFLAMMATION  Infections  Stress  Excess sugar  Toxins  Autoimmune disease  Insulin resistance 7/22/2013 17
  • 18. VITAMIN/MINERAL deficiencies, e.g.  Folate  B6  B12  Vitamin D  Zinc  Magnesium  Selenium 7/22/2013 18
  • 19. HEAVY METAL TOXICITY  Mercury -amalgam fillings -fish  Lead -paint -smoke 7/22/2013 19
  • 20. TRAUMA  Combat  Non-combat 7/22/2013 20
  • 21. RICARDO A 12-B combat engineer who suffered Traumatic Brain Injury in 2012 in Afghanistan
  • 22. RICARDO  U.S. citizen born in South America  H.S. grad, enlisted at 26 now 28  Wife and sons 6 and 7  No prior medical history  Afghanistan 2011-2012: 12B infantry  Combat engineer “search for explosives if found detonate them”  Learned Pashto, conversed with villagers  Multiple IED exposures and unit casualties  Feb 2012: gunner on RG 31, near rollover-  Concussion 850.9, loss of consciousness  Currently in treatment for TBI in U.S.
  • 23. CURRENT SYMPTOMS  photo sensitivity  nausea  headaches 2 x / day  poor sleep 4-5 hours  left ear tinnitus ……………………………………………..  dizziness  vertigo, anxiety  photophobia (wears sunglasses)  malaise/fatigue  Irritability  emotional lability  apathy  memory loss that began 3 months post concussion
  • 24. DIAGNOSES  Current:  Adjustment disorder with anxiety and depression  Memory loss; post combat stress symptoms ………………………………………………..  Per prior post:  PTSD not warranted  Depression not warranted
  • 25. REFERENCES  2001 TED presentation- Sherwin Nuland on ECT  World Health Organization- Global Burden of Disease- 2004  Murrough JW and Charney DS Cracking the Moody Brain: Lifting the mood with ketamine Nature Medicine 16.1384-1385 (2010)  Messer MM and Haller IV Maintenance Ketamine Treatment Produces Long-Term Recovery from Depression Primary Psychiatry 2010;17(4): 48-50  Murrough JW et al Safety and efficacy of repeated-dose intravenous ketamine for treatment-resistant depression http://www.ncbi.nlm.nih.gov/pubmed/19897179  Zarate CA et al A Randomized Add-on Trial of an N- methyl-D aspartate Antagonist in Treatment-Resistant Bipolar Depression Arch Gen Psychiatry 2010;67 (8):793-802 7/22/2013 25
  • 26. REFERENCES cont’d  Stahl, Stephan. Essential Psychopharmacology: The Prescriber’s Guide. Cambridge University Press, New York, NY 2008.  Herman, Judith. Trauma and Recovery. Basic Books, NYC, NY 1997.  Doidge, Norman. The Brain That Changes Itself. Penguin Books, London, England 2007.  Hyman, Mark. The Ultra Mind Solution. Scribner, New York, NY 2009.  Restak, Richard. Optimizing Brain Fitness. The Great Courses, Chantilly, VA. 2011. 7/22/2013 26

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