This document discusses mood disorders, specifically depression. It provides the DSM-IV criteria for a major depressive episode, including symptoms such as depressed mood, diminished interest, changes in appetite, insomnia, fatigue, feelings of worthlessness, difficulty concentrating, and suicidal thoughts. It also discusses treatment options, focusing on pharmacotherapy. SSRIs are considered a first-line treatment and details are provided about specific SSRIs, their mechanisms of action, indications, and precautions. Risk factors for suicide are briefly covered.

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

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
1. Guarantee patient safety
2. Complete diagnostic evaluation of the
patient
3. 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

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
 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

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