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  • 1. Depression, Suicide
  • 2.
    • Chapter 15
      • 15.1 pages 527 to 562
  • 3. Mood Disorders: Depression
    • Mood is a pervasive and sustained feeling that is experienced internally and that influences a person's behavior and perception the world.
  • 4. Depression
    • Mood can be:
      • normal,normal,
      • elevated,elevated,
      • or depressed.or depressed.
      • Healthy persons experience a wide range of  moods and have an equally large repertoire of affective expressions; they feel in control of their moods and affects.
  • 5. Mood Disorder: Depression
    • Mood disorders are a group of clinical conditions characterized by a loss of tha that sense of control and a subjective experience of great distress.of great distress.
    • Patients with elevated mood demonstrate expansiveness, flight of ideas, decreased sleep, and grandiose ideas.
    • Patients with depressed mood experience a loss of energy and interest, feelings of guilt,,difficulty in concentrating, loss of appetite,and thoughts of death or suicide.
    • Other signs and symptoms of mood of mooddisorders include change in activity level,,cognitive abilities, speech, and vegetative functions (e.g., sleep, appetite, sexualfunctions (e.g., sleep, appetite, sexualactivity, and other biological rhythms).
    •   These disorders virtually always result in  impaired interersonal, social, and occupational functioning
  • 6. DSM-IV-TR Criteria for Major Depressive Episode Table 15.1-5-6
    • Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either
      • (1) depressed mood or
      • (2) loss of either loss of interest or pleasure.
  • 7. DSM-IV-TR Criteria for Major Depressive Episode
    • Note:
      • Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations
      • Depressed mood most of the day, nearly every day,as indicated by either subjective report (e.g., feels sad or empty) or observation made by others).appears tearful)
  • 8. DSM-IV-TR Criteria for Major Depressive Episode
    • markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day, (as indicated by either subjective account or observations by others)
    • significant weight loss when not dieting or weight gain (e.g., a change of more than 5% weight in a month), or decrease or increase in appetite nearly every day.
    • Note
    •   In children, consider failure to make expectedIn children, consider failure to make expected weight gains.
  • 9. DSM-IV-TR Criteria for Major Depressive Episode
    • insomnia or hypersomnia nearly every day
    • psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
  • 10. DSM-IV-TR Criteria for Major Depressive Episode
    • fatigue or loss of energy nearly everyday
    • feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every (not merely self-reproach or guilt about being sick)
    • diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
    • recurrent thoughts of death (not just fear of recurrent fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan, or a suicide attempt or a specific plan for committing suicide.
  • 11. Treatment
    • Guarantee patient safety
    • Complete diagnostic evaluation of the patient
    • Treatment plan that addresses:
      • Immediate symptoms
      • Patient ’s prospective well-being
  • 12. Pharmacotherapy
    • Once a diagnosis has been established a pharmacological treatment strategy can be formulated
    • Objective:
      • Symptom remission not just reduction
  • 13. Pharmacotherapy
    • Major depressive disorder
    • Most antidepressants have a lag period of 10 days to approximately 4 weeks before a therapeutic response is noted
    • Increasing dose will not shorten this period, it will increase the incidence of adverse reactions
  • 14. Pharmacotherapy
    • Antidepressants
      • 3 main classes
        • Selective serotonin reuptake inhibitors (SSRIs)
        • Tricyclic Antidepressants ( Tas)
        • Mono amine oxidase Inhibitors (MAOIs)
      • All three classes work differently but all change brain chemistry to improve neurotransmission.
  • 15. Pharmacotherapy
    • Therapeutic response
      • Not all patients respond the same way to a medication
      • IF a patient fails to respond appropriately to an antidepressant, he or she may respond positively to another antidepressant, including another drug of the same pharmacologic class
      • Similar positive responses to drug therapy can be obtained by augmenting the original drug with a drug of a different class.
  • 16. SSRIs
    • SSRIs are the first choice in treating depression
      • They are preferred over TAs and MAOIs
        • Less damaging to the heart
        • Minimal anticholinergic effects
        • Minimal hypotensive effects
      • Fluoxetin (Prozac) 1987, became the first SSRI approved by the FDA for use as antidepressant.
      • Currently sertraline (Zoloft) is one of the most widely used antidepressants in the United States.
      • Readings- Chapter 36.29 pg 1083-1090
      • See tables 36.29-1 and 36.29-2
  • 17. SSRIs
      • Pharmacokinetics
        • SSRIs have a broad range of serum half- lives
          • Fluoxetine has the longest half-life- 4 to 6 days; its active metabolite has a half-life of 7-9 days
        • SSRIs are well absorbed, peak effects range from 3 to 8 hours
        • All SSRIs are metabolized by the liver by cytochrome P450 (CYP) enzymes
        • Most interaction activities are related to inhibition of metabolism of coadministered medications.
  • 18. Pharmacodynamics
    • SSRIs:
      • Exert their therapeutic effects through 5HT reuptake inhibition
      • Higher dosages do not increase antidepressant efficacy- may increase incidence of adverse effects
      • Citalopram and escitalopram are the most selective of the SSRIs
      • Other SSRIs also have actions on norepinephrine and dopamine receptors, causing reuptake inhibition.
  • 19. Therapeutic Indication
    • In the US all SSRIs, except fluvoxamine have FDA approval for use in the treatment of depression.
    • Studies have found that antidepressants with serotonin-norepinephrine activity (MAOIs TCAs) produce higher rates of remission than SSRIs
      • Venlafaxine & mirtazapine
    • In the past SSRIs have been link to a slight increase in suicide ideation. However the relation remains unclear
    • A noted increase in anxiety and agitation has been seen in some patients
  • 20. Pregnancy and Postpartum Depression
    • Postpartum depression affects a small percentage of mothers
    • 68 to 100 percent relapse in pregnant patients that discontinue therapy
    • Evidence suggests increased rates of special care nursery admission after delivery for children of mothers on SSRIs
    • SSRIs are secreted in breast milk; however [plasma] levels are usually very low in mothers that are breast feeding.
  • 21. Depression in the Elderly
    • SSRIs are safe and well tolerated when used in the elderly and medically ill
      • Little or no cardiotoxic effects
      • Little or no anticholinergic effects
      • Little or no antihistaminergic effects
      • Little or no alpha-adrenergic adverse effects
  • 22. Depression in Children
    • Only fluoxetine has FDA approval for use as an antidepressant in this population
    • Reports indicate that SSRIs can increase suicidal and violent thoughts or actions in depressed children
    • Children treated with SSRIs require close monitoring
  • 23. Precautions and Adverse Reactions
    • Sexual dysfunction
      • Most common adverse effect of SSRIs
    • GI
      • Very common, mediated largely through the effects on the serotonin 5HT receptors
        • Nausea
        • Diarrhea
        • Anorexia
        • Vomiting
        • Flatulence
        • Dyspepsia
  • 24. Precautions and Adverse Reactions
    • Headaches
      • 18 to 20 percent of cases
    • CNS adverse effects
      • Anxiety
        • First few weeks
      • Insomnia & Sedation
        • Improved sleeping resulting from treatment of depression and anxiety
        • Vivid dreams
  • 25. Precautions and Adverse Reactions
    • CNS adverse effects (cont.)
      • Emotional blunting
        • Inability to express emotions
      • Yawning
      • Seizures
        • 0.1 to 0.2 percent
      • Extrapyramidal Symptoms
    • Anticholinergic Effects
      • Paroxetine
        • Mild anticholinergic effects
    • Hematologic Adverse effects
      • Can cause functional impairment of platelet aggregation
        • Easy bruising, prolonged bleeding
      • Special monitoring suggested for patients on SSRIs and anticoagulants
  • 26. Precautions and Adverse Reactions
    • Electrolyte and Glucose Disturbances
      • SSRIs may decrease [glucose]
        • Careful monitoring for diabetic patients suggested
    • Endocrine and Allergic Reactions
      • SSRIs can decrease prolactin levels
        • Mammoplasia and galactorrhea in both men and women
        • Various types of rashes- 4% of patients
    • Serotonin syndrome
      • Concurrent administration of an SSRI with MAOI, L-Tryptophan or lithium can raise plasma [serotonin] to toxic levels
  • 27. Precautions and Adverse Reactions
    • Sweating
      • Experienced by some patients while on SSRIs
    • SSRI withdrawal
      • May exhibit withdrawal symptoms upon sudden discontinuation
      • Drug interactions see table 36.29-3
  • 28.  
  • 29.  
  • 30.  
  • 31. Suicide
    • Primary emergence for the mental health professional
    • Major public health problem
    • Over 30,000 persons commit suicide each year in the US
    • More than 600,000 attempt suicide
  • 32. Suicide: Risk Factors
    • Gender
    • Age
      • 15-44
    • Race
      • More common among white males
    • Religion
      • Higher in Protestants and Jews than Roman Catholics
    • Marital Status
      • Single, never married persons are twice more likely to comit suicide than married persons.
      • Divorce increases the likelihood of suicide
      • Widows also have a higher rate
  • 33. Suicide: Risk Factors cont.
    • Social Status
      • The higher the person ’s social status, the higher the incidence
      • A fall in social status also increases the risk of suicide
    • Occupations
      • Both males and female physicians in the US have increase rates of suicide
    • Climate
      • No significant data indicates a correlation with climate and suicide.
    • Physical Health
      • The relation of physical health and illness to suicide is significant
    • Mental Health
      • Almost 95% of all persons who commit suicide have a diagnosed mental illness.
  • 34. Suicide: Risk Factors cont.
    • Psychiatric Patients
      • Psychiatric patients ’ risk for suicide is 3 to 12 times that of non psychiatric patients.
        • Depressive disorders
        • Schizophrenia
        • Alcohol Dependence
        • Other Substance dependence
        • Personality Disorders
  • 35. Suicide: Treatment
    • Decision to hospitalize a patient with suicidal ideation depends on:
      • Severity of depression
      • Severity of suicidal ideation
      • Patient ’s family’s coping ability
      • Patient ’s living situation
      • Availability of social support
      • Absence or presence of risk factors for suicide
  • 36. Suicide: Pharmacotherapy
    • Patients hospitalized can receive medication for underlying diagnoses, leading to suicide ideations or attempts:
      • Antidepressants
      • Antipsychotics
      • When patients present signs of both, medications like risperidone (Risperdal) that have both antipsychotic and antidepressant effects are very useful.
      • Vigorous treatment should be initiated depending onunderlying disorder.
      • Supportive psychotherapy is also indicated.
    • ECT may be necessary for severely depressed patients