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Depression: What Is It and What Are My Treatment Options? (Community Lecture)

In this community lecture, Summit Medical Group practitioners share insights regarding the warning signs of depression and offer options for treatment, including therapy and medication.

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Depression:
              What is it & What are my
               Treatment Options?
                           Presented by:
Elizabeth Nikol, LCSW, ACT             Dr. Lauren Kaplan-Sagal
Sr. Behavioral Health Clinician               Psychiatrist

       SMG Behavioral Health & Cognitive Therapy Center
                      January 12, 2012
Agenda
•   What is Depression?
•   Statistics
•   Types of Depression
•   Consequences of Depression
•   The Neurotransmitter’s Role in Depression
•   Medication Options
•   The Role of Our Thoughts in Depression
•   Cognitive Therapy
•   Q&A
Statistics – National Institute of Mental Health
  (NIMH) and the Center for Disease Control
                      (CDC)
• In a 12 month period, 9.5% of adults suffer with some form
  of depression
• 45% of these are classified as severe
• Only 50% of these people seek treatment
• Ages 45 – 64 have the highest incidence, but average age of
  onset is 30
• Women are more likely to suffer from some form of
  depression
• Other risk factors: Less education, those previously
  married, the unemployed.
Statistics: Robert Leahy, PhD

• 1 in 5 people will experience depression in their
  lifetime
• 20% are still depressed two years after onset
• 59% of those with depression also suffer with
  anxiety
• 24% have substance abuse disorders
• Depressed people are 30 times more likely to
  commit suicide
What is Depression?

According to the American Psychiatric Association:

•   Depressed mood or extreme sadness
•   Loss of pleasure or interest in most things that you usually enjoy
•   Significant weight loss or gain
•   Difficulty sleeping (too much or too little)
•   Feeling either restless or slowed down
•   Being tired all the time
•   Having feelings of worthlessness or guilt
•   Difficulty thinking or concentrating
•   Repeated thoughts of death or dying

(Needs to be for at least 2 weeks & nearly every day)
Difference between Sadness and
             Depression
• Sadness lasts for a short period of time, whereas
  depression can last for weeks or months at a time.
• Sadness usually does not impact a person’s ability to
  function productively, whereas depression can.
• Sadness is often times realistic in thought pattern,
  whereas depressed thoughts can be distorted and
  unrealistic.
• Depression involves feelings of hopelessness and
  helplessness.
• Depression is an illness.

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Depression: What Is It and What Are My Treatment Options? (Community Lecture)

  • 1. Depression: What is it & What are my Treatment Options? Presented by: Elizabeth Nikol, LCSW, ACT Dr. Lauren Kaplan-Sagal Sr. Behavioral Health Clinician Psychiatrist SMG Behavioral Health & Cognitive Therapy Center January 12, 2012
  • 2. Agenda • What is Depression? • Statistics • Types of Depression • Consequences of Depression • The Neurotransmitter’s Role in Depression • Medication Options • The Role of Our Thoughts in Depression • Cognitive Therapy • Q&A
  • 3. Statistics – National Institute of Mental Health (NIMH) and the Center for Disease Control (CDC) • In a 12 month period, 9.5% of adults suffer with some form of depression • 45% of these are classified as severe • Only 50% of these people seek treatment • Ages 45 – 64 have the highest incidence, but average age of onset is 30 • Women are more likely to suffer from some form of depression • Other risk factors: Less education, those previously married, the unemployed.
  • 4. Statistics: Robert Leahy, PhD • 1 in 5 people will experience depression in their lifetime • 20% are still depressed two years after onset • 59% of those with depression also suffer with anxiety • 24% have substance abuse disorders • Depressed people are 30 times more likely to commit suicide
  • 5. What is Depression? According to the American Psychiatric Association: • Depressed mood or extreme sadness • Loss of pleasure or interest in most things that you usually enjoy • Significant weight loss or gain • Difficulty sleeping (too much or too little) • Feeling either restless or slowed down • Being tired all the time • Having feelings of worthlessness or guilt • Difficulty thinking or concentrating • Repeated thoughts of death or dying (Needs to be for at least 2 weeks & nearly every day)
  • 6. Difference between Sadness and Depression • Sadness lasts for a short period of time, whereas depression can last for weeks or months at a time. • Sadness usually does not impact a person’s ability to function productively, whereas depression can. • Sadness is often times realistic in thought pattern, whereas depressed thoughts can be distorted and unrealistic. • Depression involves feelings of hopelessness and helplessness. • Depression is an illness.
  • 7. Other Types of Depression • Adjustment Disorder with Depressed Mood • Bipolar I and II • Postpartum Depression • Dysthymia • Cyclothymia • Seasonal Affective Disorder • Pre-menstrual Dysphoric Disorder
  • 8. Why Does Someone Become Depressed? • Physical (Biochemical/Genetics) • Behavioral • Cognitive • Situational or Environmental
  • 9. Consequences of Depression Higher rates of work absences and disability Increase rate of disease and physical symptoms (i.e. headaches, back pain, gastro issues, etc.) Less productivity at work and home Poor lifestyle choices Relationship difficulties Suicide
  • 10. “So, you’re telling me I have a chemical imbalance?” 3 Neurotransmitters Likely Involved in Depression • Dopamine • Serotonin • Norepinephrine
  • 12. Medications • SSRI’s: Celexa, Lexapro,Prozac, Luvox, Paxil, Zoloft • SNRI’s: Effexor (Venlafaxine) , Pristique (also Venlafaxine) • Dopamine-Norepinephrine Reuptake Inhibitors: Wellbutrin (Bupropion):
  • 13. Medications • Norepinephrine-serotonin modulator: Mirtazapine (Remeron) • MAOI’s: Phenelzine, Tranylcypromine, Moclobemide • Serotonin modulators: Trazadone
  • 14. Medications • Tricyclic Antidepressants (tertiary amines/secondary amine/tetracyclics): Amitriptyline, Clomipramine, Doxepin, Imipramine, Trimipramine, Desipramine, Nortriptyline, Protriptyline, Amoxapine, Maprotiline • Mood Stabilizers/Major Tranquilizers: Risperdal, Abilify, Seroquel, Zyprexa, Geodon
  • 15. Electroconvulsive Therapy (ECT) • Used to be called "electroshock" therapy • Electrodes are placed to the head, and a seizure is induced • Causes change the brain chemistry and can relieve severe depression symptoms • Considered for patients with major depressive disorder with a high degree of symptom severity (catatonia, psychotic symptoms, etc) and functional impairment • Also selected for emergence, such as a when someone is refusing to eat, is nutritionally compromised or actively suicidal and not responding to other interventions.
  • 16. Other interventions • Bright Light Therapy: mostly used for SEASONAL AFFECTIVE DISORDER, but is beginning to be introduced in other forms of depression and for those who are unable to tolerate medication for a variety of reasons. • Other treatments just starting to be used in research settings or in specialty areas – Vagus Nerve stimulation (VNS), approved for intractible epilepsy and refractory depression • Jury still out on how effective it is. • Requires surgery for placement of the device.
  • 17. Other interventions (con’t) • Transcranial Magnetic Stimulation (TMS) – Uses transcranial pulsed magnetic fields – No siezure, but molecular changes are suspected to occur – Jury is still out on this as well, but some people are doing it – Does not require surgery
  • 18. Other Medical Conditions That Mimic Depression – Need to Rule Out • Thyroid condition • Cardiac condition • Certain Pancreatic conditions • Anemia • B12 or Folic Acid deficiency (certain vitamin deficiency) • Viral infections (eg. Lyme disease, Influenza post- viral infection)
  • 19. Criteria used to determine when medication is needed • Mild vs. Moderate vs. Severe Depression • Psychosocial or interpersonal issues • Previous response to medication (combination necessary?) • Effectiveness • Side effects • Risk of suicide
  • 20. Most optimal • The medications used and found to be most optimal for most patients: • SSRI’s (Prozac, Zoloft, Lexapro, Paxil) • Buproprion (Wellbutrin) • SNRI’s: Venlefaxine (Effexor, Pristique) or Cymbalta • Monoamine Oxidase Inhibitors (MAOI’s) are most often restricted to patients who do not respond to other treatments because of their potential for serious side effects and the necessity for dietary restrictions
  • 21. Possible Side Effects • Cardiovascular • Anticholinergic: (mostly from Tricyclics): Dry mouth, constipation, urinary Hesitancy, visual changes, confusion, sedation, weight gain, GI (nausea, vomiting, diarrhea), insomnia • Neurological: Myoclonus, Extrapyramidal (joint stiffness) and TARDIVE DYSKINESIA— irreversible involuntary muscle movement, seizures (Wellbutrin, amoxapine), headaches • Sexual side effects: arousal, erectile dysfunction, orgasm dysfunction, Priapism (TRAZADONE) • SEROTONIN SYNDROME: often dose related
  • 22. Length of time for treatment • After 4-8 weeks a patient should begin to notice moderate improvement • Once a patient is feeling the symptom that brought the patient in for treatment, one counts 9-12 months from that day of treatment relief for the possibility of tapering off the medication. • If a person has more than one episode of Major Depression, the recommendation is for that individual to remain on medication to prevent relapse and recurrence.
  • 23. Risk Factors for Recurrence of Major Depressive Disorder • Prior History of multiple episodes of MDD • Persistence of depression symptoms after recovery of the episode • Presence of additional psychiatric issues (substance abuse, panic or anxiety disorders…) • Presence of a chronic general medical condition
  • 24. Other Conditions Requiring Psychiatric Evaluation and Intervention • Post-Partum Depression (and Peri-Partum Depression) o A patient with a known diagnosis of depression should, whenever possible, have a planned pregnancy and in consultation with a Psychiatrist understand the risks of being on medication while pregnant. o If one can be off all medication prior to conception, that should be done in consultation and with careful monitoring throughout pregnancy. o However, there are times when a woman may need to be on medication while pregnant and all the risks and fetal effects should be reviewed.
  • 25. Therapeutic Interventions: Cognitive Behavioral Therapy (CBT) • Pioneers: Aaron Beck and Albert Ellis • Negative thinking encourages and continues depression and anxiety • These thought processes help to engage self defeating behaviors • Together the therapist and patient work to evaluate thinking, make changes where necessary and problems solve • New behaviors are created • Effectiveness confirmed in numerous studies • Short-term treatment
  • 26. Negative Cognitions • Self • Others • The future
  • 27. Cognitive Distortions • Emotional Reasoning • Overgeneralization • Arbitrary Inference • All or Nothing Thinking • Should statements • Mind reading • Fortune Telling • Selective negative focus • Disqualifying the Positive • Catastrophizing • Personalizing • Labeling
  • 28. Thought Record & Socratic Questions • What evidence/facts do I have that supports my thought? • What evidence/facts do I have that counters my thought? • Alternative explanations? • What are the advantages of thinking this way? • What are the disadvantages of thinking this way?
  • 29. Thought Record & Socratic Questions • What is the worst that could happen? Could I live through it? • What would I tell a friend with the same thought? • Is this thought a cognitive distortion? • What would I like to think instead?
  • 30. Behavioral Activation • Depressed people act depressed • Few activities that are pleasurable or achievement oriented • Track activities for one week • Score 1 – 10 for pleasure (P), achievement (A) and depression (D) • As pleasure and achievement go up, depression goes down • Activity scheduling
  • 31. Mindfulness • A way of experiencing the world based in Buddhist tradition • Fully aware • Staying in the present moment • Observing thoughts without judging them • Actively change relationship to the thoughts • Watch them come about and then actively move away • Move away from doing and focus on being • Experiential Exercise
  • 32. Resources • Mind Over Mood – Dennis Greenberger & Christine Padesky • The New Feeling Good – David Burns, MD • Beat the Blues Before They Beat You – Robert L. Leahy • Overcoming Depression Once Step at a Time – Michael Addis & Christopher Martell • The Mindful Way Through Depression – Zindel Segal, Mark Williams, John Teasdale & Jon Kabat-Zinn • SMG Behavioral Health and Cognitive Therapy Center: http://www.summitmedicalgroup.com/service/Behavioral-Health-and- Cognitive-Therapy-Center/ • Academy of Cognitive Therapy website: http://www.academyofct.org • Mindfulness Center of NJ: http://www.mindfulnessnj.com
  • 33. For more information • Visit http://www.summitmedicalgroup.com • Call (908) 508-8909

Editor's Notes

  1. Adjustment Disorder with Depressed Mood: a psychological response to an identifiable stressor or group of stressors that cause(s) significant emotional or behavioral symptoms that do not meet criteria for major depressive disorder Bipolar I and II: historically known as manic–depressive disorder, A mental illness that causes people to have severe high and low moods. People with this illness recurrently switch from feeling overly happy and joyful (or irritable) to feeling very sad and hopeless (or extreme unhappiness). In between mood swings, a person's moods may be normal. BIPOLAR I:One or more manic episodes. Subcategories specify whether there has been more than one episode, and the type of the most recent episode.[47] A depressive or hypomanic episode is not required for diagnosis, but it frequently occurs. Bipolar II disorder:No manic episodes, but one or more hypomanic episodes and one or more major depressive episode.Hypomanic episodes do not go to the full extremes of mania (i.e., do not usually cause severe social or occupational impairment, and are without psychosis), and this can make bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing, crippling depression. Postpartum Depression: Postpartum depression is a complex mix of physical, emotional and behavioral changes that occur in a mother after giving birth. It is a serious condition, affecting about 10% of new mothers. Symptoms range from mild to severe depression and may appear within days of delivery or gradually, perhaps up to a year later. Symptoms may last from a few weeks to a year.Dysthymia: mood disorder consisting of chronic depression, with less severe but longer lasting symptoms than major depressive disorderCyclothymia: A history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes. There is a low-grade cycling of mood which appears to the observer as a personality trait, and interferes with functioning. Seasonal Affective Disorder: SAD is a depression that occurs each year at the same time, usually starting in fall or winter and ending in spring or early summer. Pre-menstrual Dysphoric Disorder: PMDD is a severe form of premenstrual syndrome (PMS) that affects about 3-5% of menstruating women. Emotional symptoms of PMDD include shifting moods, severe depression, feelings of hopelessness, anger, anxiety or low self-esteem, difficulty concentrating, irritability, and tension. Physical symptoms include fatigue, headaches, joint or muscle pain, breast tenderness, changes in appetite, food cravings or bingeing, sleep problems and bloating.