2. What Is Depression?
DSM – IV
Duration > 2 weeks Depressed mood or Marked loss of
interest or pleasure in normal activities
Plus 5 of 9 following symptoms
3. Major Depression: 5
of 9 Sx:
• Depressed mood
• Loss of interests/pleasure
• Change in sleep
• Change in appetite or weight
• Change in psychomotor activity
• Loss of energy
• Trouble concentrating
• Thoughts of worthlessness or guilt
• Thoughts about death or suicide
4. SIGECAPS
- Changes in sleep pattern
- Changes in interests or activity
- Feelings of guilt or increased worry
- Changes in energy
- Changes in concentration
- Changes in appetite
- Psychomotor disturbances
- Suicidal ideation
S
I
G
E
C
A
P
S
5. A “yes” to either question
is a positive initial screen
for depression…
Two-Steps for Depression Screening
• Over the past 2 weeks have
you felt down, depressed, or
hopeless?
• Over the past 2 weeks have
you felt little interest or
pleasure in doing things?
• PHQ-9:
Patient Health
Questionnaire-9
Step One:
Two-Question Depression Screen
Step Two: If Screen is Positive…
US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136(10):760-764
6. PHQ-9
• It is an easy-to-use patient questionnaire as a
diagnostic instrument for common mental
disorders.
• The PHQ-9 is the depression module, which
scores each of the nine DSM-IV criteria as "0"
(not at all) to "3" (nearly every day). It has
been validated for use in primary care.
• It is used to monitor the severity of
depression and response to treatment.
7.
8.
9. 5-HT and NA at the Synaptic Level: Healthy
vs. Depressed
Depressed
Healthy
NA
5-HT
5-HT Reuptake
Transporter
NA
Reuptake
Transporter
Theoretical Representation
10. Major Depressive Disorder (MDD)
Depression is a potentially life -threatening disorder
that affects hundreds of millions of people all over
the world
Women at higher risk of developing MDD (Women :
Men = 2:1)
Can happen at any age, but the highest rate was
between (18-29) years of age
it is a familial disorder (have some genetic
predisposition)
12. 1. Chemical transmission is the major means by
which nerves communicate with one another.
2. Chemical transmission requires several steps
including synthesis of the neurotransmitters,
their storage in secretory vesicles, and their
regulated release into the synaptic cleft between
pre- and postsynaptic neurons
20. When left untreated or when
treated improperly
Depression can be a life-threatening
condition
21. ABCs of CBT
You cannot control how you feel, but you
can control what you think about, and this
can influence how you feel
• Essential elements of CBT include:
– Increasing pleasurable activities
– Reducing negative thoughts
– and improving assertiveness and problem-
solving skills to reduce feelings of helplessness.
23. • Anti-depressants are not addictive or habit
forming.
• Anti-depressants take 2-3 weeks to begin to work
and need to be taken for 4-6 months after the full
benefit is obtained to prevent relapse.
24. SSRIS ON THE MARKET
• Citalopram (Celexa)
• Fluoxetine (Prozac)
• Fluvoxamine (Luvox)
• Paroxetine (Paxil)
• Sertraline (Zoloft)
27. SSRIs
Why they are better choice as compared to
TCA?
- Less sedation
- Less anticholinergic
- Less cardiovascular effects than TCAs
- Less likely to cause weight gain than TCAs
28. Side Effects of SSRI
Nausea and vomiting ?????
Insomnia and anxiety
Impotence and sexual dysfunction (in male and
female)????
Decrease weight and appetite ???
Drugs interactions due to their significant inhibitory
action at CYP450 (Except Citalopram.)
30. • Serotonin syndrome
– At high doses or combined
with other drugs an
exaggerated response can
occur
• This is due to increased
amounts of serotonin
31. SSRIs
Serotonin withdrawal syndrome
With discontinuation of any SSRI onset of withdrawal
symptoms occur within a few days and can persist 3-4
weeks
Symptoms: disequilibrium, gastrointestinal problems,
flu-like symptoms, sensory disturbances, sleep
disturbances
32. Tricyclics
• MOA – decreased reuptake of serotonin and norepinepherine
• Negligible effect on dopamine
• Side Effects
– Anticholinergic – dry mouth, constipation, urinary
retention, blurred vision, confusion
– Antihistaminic – Sedation
– Cardiac –Delayed cardiac conduction
– Weight gain (an increase in appetite due to its
histamine blocking abilities.)
– Hyperglycemia
– Sexual dysfunction
33. MAOAIs (DOPAMINE, NA ,
SEROTONIN)
PHENELZINE
Side Effects
– Hypertensive crisis with tyramine-containing product
– Serotonin syndrome
– Anticholinergic side effects
– Hepatotoxicity
– Sexual dysfunction
– Withdrawal symptoms if abruptly stopped
– Many drug-drug and drug-food interactions
34.
35. Nefazodone & Trazodone
Multifunctional drug with dose-dependent
pharmacologic actions.
That is, it has hypnotic actions at low doses due to
blockade of 5-HT2A receptors, as well as
H1 histamine receptors and α1 adrenergic
receptors.
Higher doses recruit the blockade of the serotonin
transporter (SERT) and turn trazodone into an
antidepressant.
36. Nefazodone & Trazodone
Minimal anticholinergic effect
most common S.E are sedation, dizziness,
orthostatic hypotension
black box warning “liver failure” with
Nefazodone
37. Bupropion
Bupropion works by inhibiting the reuptake of dopamine, serotonin and NE
common S.E: nausea, vomiting, tremor, insomnia, dry mouth and skin reactions
Do not use bupropion if you have used an MAO inhibitor in the past 14 days. A dangerous drug
interaction could occur.
Contraindicated in patients with seizures???
Used cautiously in hepatic patients???
It does not cause as much weight gain or sexual dysfunction.
Depression with sleepiness---------who bupropion has been found to be more effective than SSRI
Depression with anxiety -------SSRIs more effective than bupropion in the treatment of anxious
depression
38. MIRTAZEPINE
Mirtazepine (increase serotonin and NE
release) :
most common S. E: somnolence, dry mouth,
constipation and sedation
Differ from SSRI in
Increase appetite (good for patients taking
cancer chemotherapy)
No Sexual dysfunction
39. Special population: Elderly patients
SSRIs are the group of choice
Buprobion and venlafaxine can be used
because of their milder anticholinergic and
less cardiotoxic effects
40. Special population: children & adolescents
Fluoxetine is the only antidepressant approved
for patients under 18 years of age
Citalopram also accepted
Pregnancy : non-pharmacologic approach is
preferred
if not adequate, the doctor has to weigh the
risk/benefit of the treatment (SSRIs are
acceptable but not Paroxetine)
Lactation: citalopram, nortriptyline, sertraline
and paroxetine
41. St. John’s Wort
• Nonprescription herbal medication
• Some efficacy in mild to moderate depression
• Adverse effects
– GI irritation, HA, fatigue, nervousness
• Drug interactions
– Induction of CYP3A4
– Safety and efficacy combined with antidepressants
has not been studied
