Depressionsuicide 120223170018-phpapp01


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Depressionsuicide 120223170018-phpapp01

  1. 1. Depression, Suicide
  2. 2.  Chapter 15  15.1 pages 527 to 562
  3. 3. Mood Disorders: Depression Mood is a pervasive and sustained feeling that is experienced internally and that influences a persons behavior and perception the world.
  4. 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. 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. 6. DSM-IV-TR Criteria for MajorDepressive 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
  7. 7. DSM-IV-TR Criteria for MajorDepressive 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. 8. DSM-IV-TR Criteria for MajorDepressive 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. 9. DSM-IV-TR Criteria for MajorDepressive 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. 10. DSM-IV-TR Criteria for MajorDepressive 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. 11. Treatment1. Guarantee patient safety2. Complete diagnostic evaluation of the patient3. Treatment plan that addresses:  Immediate symptoms  Patient’s prospective well-being
  12. 12. Pharmacotherapy Once a diagnosis has been established a pharmacological treatment strategy can be formulated Objective:  Symptom remission not just reduction
  13. 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. 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. 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. 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. 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. 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. 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. 20. Pregnancy and PostpartumDepression 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. 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. 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. 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. 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. 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. 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. 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. 28. 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
  29. 29. Suicide: Risk Factors Gender  MORE COMMON IN MALE 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
  30. 30. 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.
  31. 31. 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
  32. 32. 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
  33. 33. 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