Depression research and treatment
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Depression research and treatment
- 1. Depression: Research and Treatment Prepared by: Dr. Shraddha Bhadada Prepared for: Turacoz Healthcare Solutions
- 2. Table of contents • Depression: Quick Facts • Depressions Signs • Treatment Options • Psychotherapy • Medications • Brain Stimulation Procedures • Life-style changes and Self-help Strategies • Alternative and Complimentary Medicines • New Research in management of depression • Concluding Remarks
- 3. DEPRESSION: QUICK FACTS 1. Cui R. Editorial: A Systematic Review of Depression. Curr Neuropharmacol. 2015;13(4):480. 2. WHO factsheet. https://www.who.int/news-room/fact-sheets/detail/depression. Accessed on Dec 31, 2020 3. Barth J, Munder T, Gerger H, Nüesch E, Trelle S, Znoj H, et al. (2013) Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis. PLoS Med 10(5): e1001454 It is a brain disease that affects mood and physical health also1. Known by low mood, sadness, inability to enjoy or sleep1. More than 264 million people worldwide suffer2. More women are affected than men2. Can lead to suicide too2. Major cause of disability. Can affect person’s performance at work, family or even at school2. Major Depressive Disorder One in six people gets affected3.
- 4. SIGNS OF DEPRESSION HELPLESSNESS DEPRESSED MOOD INABILITY TO SLEEP LONELINESS LACK OF FOCUS SUICIDAL TENDENCY LACK OF ENERGY SIGNIFICANT WEIGHT CHANGE AGITATION American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013 Presence of any of the 5 symptoms can indicate depression
- 5. TREATMENT OPTIONS Barth J, Munder T, Gerger H, et al. Comparative efficacy of seven psychotherapeutic interventions for patients with depression: A network meta-analysis. PLoS Med. 2013;10(5):e1001454. U.S. Food and Drug Administration. Depression medicines. Updated 2019. Singh A, Kar S. How electroconvulsive therapy works? Understanding the neurobiological mechanisms. Clin Psychopharmacol Neurosci. 2017;15(3);210-221. Pfeiffer PN, Heisler M, Piette JD, Rogers MA, Valenstein M. Efficacy of peer support interventions for depression: a meta-analysis. Gen Hosp Psychiatry. 2011;33(1):29-36. Lopresti A, Hood S, Drummond P. A review of lifestyle factors that contribute to important pathways associated with major depression: diet, sleep and exercise. J Affect Disord. 2013;148(1):12-27. MEDICATIONS PSYCHOTHERAPY SELF HELP STRATEGIES BRAIN STIMULATION PROCEDURES ALTERNATIVE THERAPIES
- 6. PSYCHOTHERAPY Barth J, Munder T, Gerger H, Nüesch E, Trelle S, Znoj H, et al. (2013) Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis. PLoS Med 10(5): e1001454. TALK THERAPY individualized SEVEN TYPES Support Counselling • Unstructured therapy • Talk to therapist
- 7. Interpersonal THERAPY Markowitz JC, Weissman MM. Interpersonal psychotherapy: principles and applications. World Psychiatry. 2004;3(3):136-139. TIME- LIMITED IMPROVE RELATIONSHIP SKILLS IMPROVE COMMUNICAITON SKILLS IMPROVE SOCIAL FUNCTIONING DELIVERED BY MENTAL HEALTH PROFESSIONALS INDIVIDUALIZED INTERPERSONAL COUNSELLING
- 8. Behavioral activation Kanter JW, Manos RC, Bowe WM, Baruch DE, Busch AM, Rusch LC. What is behavioral activation? A review of the empirical literature. Clin Psychol Rev. 2010 Aug;30(6):608-20. STRUCTURED ACTIVITY RELAXATION TRAINING SETTING LIFE GOALS SOCIAL CONNECTIVITY VALUE ACTIVITES TARGETS VERBAL BEHAVIOR AND AVOIDANCE
- 9. COGNITIVE Behavioral THERAPY InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Cognitive behavioral therapy. 2013 Aug 7 [Updated 2016 Sep 8]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279297/ FEELINGS THOUGHTS BEHAVIOR Problem- oriented strategy Helpful thoughts Improved mood Reduced Stress
- 10. Problem solving therapy Pierce D. Problem solving therapy - use and effectiveness in general practice. Aust Fam Physician. 2012 Sep;41(9):676-9. Identifying a problem Goal setting Deliberating various solutions Choosing a solution Designing an action plan Enjoying activities
- 11. Psychodynamic THERAPY Barth J, Munder T, Gerger H, Nüesch E, Trelle S, Znoj H, et al. (2013) Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis. PLoS Med 10(5): e1001454. LESS-INTENSIVE THAN INTERPERSONAL THERAPY SOCIAL SKILLS TRAINING IMPROVES SELF- AWARENESS FOCUS ON HEALTHY RELATIONSHIPS IMPROVE COMMUNICATION SKILLS BUILD STRONG SOCIAL NETWORK
- 12. MEDICATIONS Halverson JL, Bhalla RN, Bhalla PM, Andrew LB, Leonard RC. Depression Treatment and Management. Retrieved from https://emedicine.medscape.com/a rticle/286759-treatment#d8. Updated on Aug 2020. Accessed on Dec 31, 2020. Selective serotonin reuptake inhibitors (SSRIs) Serotonin/norepinephrine reuptake inhibitors (SNRIs) Tricyclic antidepressants (TCAs) Atypical antidepressants Monoamine oxidase inhibitors (MAOIs) N-methyl-D-aspartate (NMDA) receptor antagonists Serotonin-Dopamine Activity Modulators (SDAMs) Alternative therapies like St. John’
- 13. MEDICATIONS Hieronymus F, Lisinski A, Nilsson S, Eriksson E. Influence of baseline severity on the effects of SSRIs in depression: an item-based, patient-level post-hoc analysis. The Lancet Psy. 2019;6(9):745-752. U.S. Food and Drug Administration. Depression medicines. Updated 2019. Halverson JL, Bhalla RN, Bhalla PM, Andrew LB, Leonard RC. Depression Treatment and Management. Retrieved from https://emedicine.medscape.com/article/286759-treatment#d8. Updated on Aug 2020. Accessed on Dec 31, 2020. SSRI’s • Common – fluoxetine, citalopram, paroxetine • Severe and non-severe depression • Less side- effects SNRI’s • Common – venlafaxine, duloxetine • Newer but similar to SSRI’s • Should not be taken with MAO inhibitors SDAM’s • Brexipiprazole • Supportive therapy with other medicines
- 14. MEDICATIONS Canuso CM, Singh JB, Fedgchin M, Alphs L, Lane R, Lim P, Pinter C, Hough D, Sanacora G, Manji H, Drevets WC. Efficacy and Safety of Intranasal Esketamine for the Rapid Reduction of Symptoms of Depression and Suicidality in Patients at Imminent Risk for Suicide: Results of a Double-Blind, Randomized, Placebo-Controlled Study. Am J Psychiatry. 2018 Jul 1;175(7):620-630. Wolff A, Holzel L, Westphal A, Harter M, Kriston L. Selective serotonin reuptake inhibitors and tricyclic antidepressants in the acute treatment of chronic depression and dysthymia: a systematic review and meta- analysis. J Affect Disord. 2013;144(1-2):7-15. Halverson JL, Bhalla RN, Bhalla PM, Andrew LB, Leonard RC. Depression Treatment and Management. Retrieved from https://emedicine.medscape.com/article/286759-treatment#d8. Updated on Aug 2020. Accessed on Dec 31, 2020 MAOinhibitors • Older medicines • Not usually first choice • Common – Phenelzine, isocarboxazid, tranylcypromine NMDAantagonists • Esketamine • Used for treatment- resistant depression TricyclicAntidepressants • Oldest medicine to treat depression • Amitriptyline, Imipramine, nortriptyline • As effective as SSRI’s
- 15. Brain stimulation procedures Singh A, Kar S. How electroconvulsive therapy works? Understanding the neurobiological mechanisms. Clin Psychopharmacol Neurosci. 2017;15(3);210-221. Rizvi S, Khan AM. Use of Transcranial Magnetic Stimulation for Depression. Cureus. 2019;11(5):e4736. O'Reardon JP, Cristancho P, Peshek AD. Vagus Nerve Stimulation (VNS) and Treatment of Depression: To the Brainstem and Beyond. Psychiatry (Edgmont). 2006;3(5):54-63. TREATMENT RESISTANT DEPRESSION ELECTRO-CONVULSIVE THERAPY TRANS-CRANIAL MAGNETIC STIMULATION VAGUS NERVE STIMULATION
- 16. LIFESTYLE CHANGES and Self-Help Lopresti A, Hood S, Drummond P. A review of lifestyle factors that contribute to important pathways associated with major depression: diet, sleep and exercise. J Affect Disord. 2013;148(1):12-27. van Grieken RA, van Tricht MJ, Koeter MWJ, van den Brink W, Schene AH. The use and helpfulness of self-management strategies for depression: The experiences of patients [published correction appears in PLoS One. 2018 Dec 13;13(12):e0209109]. PLoS One. 2018;13(10):e0206262. PHYSICAL TRAINING HEALTHY DIET PROPER SLEEP ENGAGING IN LEISURE ACTIVITES DEVELOPING NEW HOBBIES JOINING SOCIAL GROUPS
- 17. ALTERNATIVE THERAPIES Nahas R, Sheikh O. Complementary and alternative medicine for the treatment of major depressive disorder. Can Fam Physician. 2011;57(6):659-663. St. JOHN WORT VITAMINS AND FOLATE ACUPUNCTURE EXERCISE OMEGA-3 FATTY ACIDS
- 18. New research In management Huang YJ, Lane HY, Lin CH. New Treatment Strategies of Depression: Based on Mechanisms Related to Neuroplasticity. Neural Plast. 2017;2017:4605971. doi:10.1155/2017/4605971 • Targeting NMDA receptors for newer medications in treating depression • Developing ketamine as an adjunct for anti- depressive medicines • Non-invasive brain stimulation : • Transcranial Direct Current Stimulation • Cranial Electrotherapy Stimulation • Magnetic Seizure Therapy
- 19. CONCLUDINGREMARKS • Depression is one of the leading causes of disability globally • However, the most severe forms of depression are also treatable • There are lot of treatment options available ranging from psychotherapy, medications to healthy lifestyle changes • “One Size fits all” does not apply to depression treatment. It has to be individualized for each patient. • Treating depression can make one happy, hopeful and able to reclaim the life again • The most common effective therapy includes psychotherapy with its different strategies • A lot of medications are also available that support the psychotherapy for better results • Healthy life-style and self-help strategies can accelerate the management of depression
- 20. Thank You
Editor's Notes
- The indications for the use of ECT include the following: Need for a rapid antidepressant response Failure of drug therapies History of good response to ECT Patient preference High risk of suicide High risk of medical morbidity and mortality Transcranial magnetic stimulation (TMS) has been approved by the FDA for the treatment of major depressive disorder when one class of antidepressant has failed. Vagus nerve stimulation (VNS) has been approved by the FDA for use in adult patients who have failed to respond to at least 4 adequate medication and/or ECT treatment regimens. The device requires surgical implantation.
- Low-sodium Dietary Approaches to Stop Hypertension (DASH) diet A study found that participants who most closely adhered to the diet were 11% less likely to become depressed over time than those least adherent to the diet The Mediterranean diet, which emphasizes fish, fruits, and vegetables, with olive oil as the main source of fat, protects cognition and can improve mental health in individuals with depression Physical activity and exercise contribute to recovery from major depressive disorder. Patients should be counseled regarding stress reduction.
- St John’s wort St John’s wort (SJW) is an extract of Hypericum perforatum, a yellow-flowering perennial herb found in temperate zones worldwide. while long-term controlled studies are needed, short-term use of SJW is as effective as antidepressant drugs, with fewer side effects. St John’s wort should not be combined with SSRIs, TCAs, or monoamine oxidase inhibitors, as this might lead to symptoms of serotonin syndrome. Folate Folate is required for the synthesis of dopamine, norepinephrine, and serotonin. Folate has been evaluated as adjunctive therapy in depression in 3 small RCTs. There is insufficient evidence to recommend folate for the treatment of depression. Because folate deficiency is associated with poorer outcomes in depression, as well as mild cognitive impairment, megaloblastic anemia, and neural tube defects, it might be reasonable to screen and treat depressed patients for folate deficiency. Acupuncture Acupuncture is a part of traditional Chinese medicine that involves inserting fine needles into specific points to restore proper flow of energy in the body. There is moderate evidence that acupuncture is not effective for treatment of depression, with most trials reporting no better outcomes than experienced by wait-list controls. Interestingly, 3 of 3 trials reported it to be as effective as antidepressant drugs, raising further questions about the efficacy of the latter. Exercise Exercise is known to make people feel good, but precisely how this occurs is not clear. Large systematic reviews suggest that exercise improves depression. Omega-3 fatty acids Docosahexaenoic acid (DHA) and eicosapentenoic acid (EPA) are long-chain polyunsaturated fatty acids, the primary dietary source of which is oily seafood. Omega-3 fatty acids show promise for the treatment of depression, but further research is needed to better understand sources of heterogeneity.
- St John’s wort St John’s wort (SJW) is an extract of Hypericum perforatum, a yellow-flowering perennial herb found in temperate zones worldwide. while long-term controlled studies are needed, short-term use of SJW is as effective as antidepressant drugs, with fewer side effects. St John’s wort should not be combined with SSRIs, TCAs, or monoamine oxidase inhibitors, as this might lead to symptoms of serotonin syndrome. Folate Folate is required for the synthesis of dopamine, norepinephrine, and serotonin. Folate has been evaluated as adjunctive therapy in depression in 3 small RCTs. There is insufficient evidence to recommend folate for the treatment of depression. Because folate deficiency is associated with poorer outcomes in depression, as well as mild cognitive impairment, megaloblastic anemia, and neural tube defects, it might be reasonable to screen and treat depressed patients for folate deficiency. Acupuncture Acupuncture is a part of traditional Chinese medicine that involves inserting fine needles into specific points to restore proper flow of energy in the body. There is moderate evidence that acupuncture is not effective for treatment of depression, with most trials reporting no better outcomes than experienced by wait-list controls. Interestingly, 3 of 3 trials reported it to be as effective as antidepressant drugs, raising further questions about the efficacy of the latter. Exercise Exercise is known to make people feel good, but precisely how this occurs is not clear. Large systematic reviews suggest that exercise improves depression. Omega-3 fatty acids Docosahexaenoic acid (DHA) and eicosapentenoic acid (EPA) are long-chain polyunsaturated fatty acids, the primary dietary source of which is oily seafood. Omega-3 fatty acids show promise for the treatment of depression, but further research is needed to better understand sources of heterogeneity.
- St John’s wort St John’s wort (SJW) is an extract of Hypericum perforatum, a yellow-flowering perennial herb found in temperate zones worldwide. while long-term controlled studies are needed, short-term use of SJW is as effective as antidepressant drugs, with fewer side effects. St John’s wort should not be combined with SSRIs, TCAs, or monoamine oxidase inhibitors, as this might lead to symptoms of serotonin syndrome. Folate Folate is required for the synthesis of dopamine, norepinephrine, and serotonin. Folate has been evaluated as adjunctive therapy in depression in 3 small RCTs. There is insufficient evidence to recommend folate for the treatment of depression. Because folate deficiency is associated with poorer outcomes in depression, as well as mild cognitive impairment, megaloblastic anemia, and neural tube defects, it might be reasonable to screen and treat depressed patients for folate deficiency. Acupuncture Acupuncture is a part of traditional Chinese medicine that involves inserting fine needles into specific points to restore proper flow of energy in the body. There is moderate evidence that acupuncture is not effective for treatment of depression, with most trials reporting no better outcomes than experienced by wait-list controls. Interestingly, 3 of 3 trials reported it to be as effective as antidepressant drugs, raising further questions about the efficacy of the latter. Exercise Exercise is known to make people feel good, but precisely how this occurs is not clear. Large systematic reviews suggest that exercise improves depression. Omega-3 fatty acids Docosahexaenoic acid (DHA) and eicosapentenoic acid (EPA) are long-chain polyunsaturated fatty acids, the primary dietary source of which is oily seafood. Omega-3 fatty acids show promise for the treatment of depression, but further research is needed to better understand sources of heterogeneity.