This was a lecture in the course "Significant Medical Conditions in Seniors" presented at Peer Learning in Chapel Hill, NC, USA in 2016 by Michael C. Joseph, MD, MPH.

1. DEPRESSION
Michael C. Joseph, MD
(Peer Learning)
September 28, 2016

2. OUTLINE
 DEPRESSION
−Definition & Significance
−Epidemiology
−Symptoms
−Subtypes
−Treatment
 RESOURCES
 CREDITS

3. Definition and Significance
 Definition
− Depression is a mood disorder that causes a persistent feeling of
sadness and loss of interest. It affects how one feels, thinks and
behaves and can lead to a variety of emotional and physical
problems. One may have trouble doing normal day-to-day
activities, and may feel as if life isn’t worth living.
 Depression & Suicide
− Depression is present in at least 50 percent of all suicides.
 The lifetime risk of suicide among patients with untreated depression
ranges from 2.2% to 15%.
 Those suffering from depression are at 25 times greater risk for suicide
than the general population.
 Instances of suicide in men is almost four times greater than in women.
However, women have higher rates of suicide ideation and attempts. The
difference is attributed to men choosing more effective methods resulting
in the higher rate of success.

4. Signs & Symptoms
Mood
• Sad, anxious or “empty”
feelings
• Feelings of hopelessness
or pessimism
• Feelings of guilt,
worthlessness, or
helplessness
• Suicidal ideation
• Irritability, restlessness
• Loss of interest in once-
pleasurable activities
Other
• Fatigue and decreased
energy
• Sleep disturbances
• Appetite changes,
especially overeating
• Decreased mental
concentration
• Memory disturbances
• Somatic complaints,
especially pain

5. Epidemiology
 Depression affects more than 17 million Americans
 1 in 5 adults in the U.S. are treated for depression at some
time in their lives
 Depression tends to run in families
 Women are 2 to 3 times more likely to be treated for
depression as men
 Adult blacks are 20 percent more likely to report serious
psychological distress than adult whites, but many African-
Americans see depression as a sign of weakness, and not a
health issue.

6. Major Depressive Disorder
 You may hear your doctor call this Major
Depressive Disorder (MDD).
 You might have this type if you feel depressed
most of the time for most days of the week for 2
weeks or longer.
 Talk therapy and antidepressants can help.
 Electroconvulsive therapy (ECT) uses
electrical pulses, and Repetitive Transcranial
Magnetic Stimulation (rTMS) uses a magnet,
to increase brain activity in areas that control
your mood.

7. Persistent Depressive Disorder
 Depression that lasts for 2 years or longer
is called Persistent Depressive
Disorder.
 It used to be known as “dysthymia”.
 You may be treated with psychotherapy,
medication, or a combination of the two.

8. Seasonal Affective Disorder
 Seasonal Affective Disorder (SAD)is a
period of Major Depression that most often
occurs during the winter months, when the
days grow short and you get less sunlight.
 Antidepressants and “light therapy” can
help. You'll need to sit in front of a special
bright light box for about 15-30 minutes each
day.

9. Psychotic Depression
 People with Psychotic Depression have the symptoms of
Major Depression, along with "psychotic" symptoms, such
as:
− hallucinations (seeing or hearing things that aren't there),
− delusions (false beliefs), or
− paranoia (wrongly believing that others are trying to harm you).
 A combination of antidepressant and antipsychotic drugs
can treat psychotic depression.
 ECT may also be an option.

10. Situational Depression
 Situational Depression is not a technical
term in psychiatry. But you can have a
depressed mood when you're having trouble
managing a stressful event in your life, such
as a death in your family, a divorce, or losing
your job.
 Your doctor may call this “Stress Response
Syndrome."
 Psychotherapy can often help you get
through a period of depression that's related
to a stressful situation.

11. Female Variants
 Premenstrual Dysphoric Disorder (PMDD)
− Women with PMDD have depression and other
symptoms at the start of their period.
− Antidepressant medication or sometimes oral
contraceptives can treat PMDD.
 Postpartum Depression
− Women who have Major Depression in the weeks and
months after childbirth may have PMDD.
− Antidepressant drugs can help.

12. Atypical Depression
 Atypical Depression is different than the
persistent sadness of typical depression.
 If you have Atypical Depression, a positive
event can temporarily improve your
mood.
 Antidepressants can help.

13. Bipolar Disorder
 Someone with Bipolar Disorder, which used
to be called “Manic Depression”, has mood
episodes that range from extremes of high
energy with an "up" mood to low
"depressive" periods.
 When you're in the low phase, you'll have the
symptoms of Major Depression.
 Whether you're in a high or a low period,
your doctor may suggest a mood stabilizer,
such as lithium.
 Psychotherapy can also help support you and
your family.

14. Bipolar Disorder/Antidepressants
 The FDA has approved three medicines to
treat the depressed phase: Seroquel,
Latuda, Olanzapine-fluoxetine combination.
 Your doctor might not recommend an
antidepressant for this condition, because it
carries a small risk of putting you into a
"high" phase. Also, there's no proof from
studies that these drugs are helpful in
treating depression in people with Bipolar
Disorder.

15. Treatment Issues
 The treatment of depression is effective only 60-
80% of the time.
 As a rule of thumb, only 1/3 of patients respond
to each course of antidepressants.
 In developed countries with well-organized
health care systems, between 44%-70% of
patients with depression do not receive
treatment in any given year.
 If left untreated, depression can lead to co-
morbid mental disorders, recurrent depressive
episodes, and higher rates of suicide.

16. Common Treatments
 Most commonly prescribed antidepressants:
− Selective Serotonin Reuptake Inhibitors (SSRIs) - Zoloft, Celexa,
Prozac, Lexapro, Paxil;
− (Serotonin Antagonists and Reuptake Inhibitors) (SARIs) –
Desyrel;
− Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) – Effexor,
Cymbalta;
− Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs) –
Wellbutrin.
 Estrogen has shown limited efficacy of treating
premenstrual- related depression; in post-menopausal
women estrogen has some effect in treating depression
and may enhance the effectiveness of antidepressants.
 Major non-drug treatments include psychotherapy,
shock therapy (ECT), and exercise.

17. Common Side Effects of
Antidepressants
 General: insomnia, fatigue, dizziness, drowsiness.
 Gastrointestinal: dry mouth (includes dryness of the
mucous membranes in the mouth, throat, and nostrils),
increased appetite and weight gain, nausea, constipation.
 Neuropsychiatric: anxiety, agitation, irritability, blurred
vision.
 Sexual: loss of sexual desire and other sexual problems,
such as Erectile Dysfunction (ED) and decreased orgasm.
 Long-term side effects include Tachyphylaxis (tolerance)
(“Prozac Poop-Out”); possibly an increased risk of Type
II Diabetes.

18. Psychotherapy
 Cognitive-Behavioral Therapy (CBT)
helps patients restructure negative
thought patterns
 Interpersonal Therapy (IPT) helps
patients understand and work through
troubled relationships

19. RESOURCES
 National Institute of Mental Health
 https://www.nimh.nih.gov
 NIH Senior Health
 http://nihseniorhealth.gov
 Depression and Bipolar Support
Alliance (DBSA)
 www.dbsalliance.org

20. CREDITS
 National Institute of Mental Health
 https://www.nimh.nih.gov/health/topics/depression/index.shtml
 NIH Senior Health
 http://nihseniorhealth.gov/depression/aboutdepression/01.htm
 Depression and Bipolar Support Alliance (DBSA) www.dbsalliance.org
 SLIDESHARE.NET
− http://www.slideshare.net/mhnsathish/depression-
10769797?utm_source=slideshow02&utm_medium=ssemail&utm_campaign=share_slideshow
− http://www.slideshare.net/CMoondog/depression-powerpoint-
13945746?utm_source=slideshow02&utm_medium=ssemail&utm_campaign=share_slideshow
− http://www.slideshare.net/CMoondog/depression-
8844385?utm_source=slideshow02&utm_medium=ssemail&utm_campaign=share_slideshow
 https://en.wikipedia.org/wiki/Major_depressive_disorder