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  1. 1. Depression, Suicide
  2. 2. <ul><li>Chapter 15 </li></ul><ul><ul><li>15.1 pages 527 to 562 </li></ul></ul>
  3. 3. Mood Disorders: Depression <ul><li>Mood is a pervasive and sustained feeling that is experienced internally and that influences a person's behavior and perception the world. </li></ul>
  4. 4. Depression <ul><li>Mood can be: </li></ul><ul><ul><li>normal,normal, </li></ul></ul><ul><ul><li>elevated,elevated, </li></ul></ul><ul><ul><li>or depressed.or depressed. </li></ul></ul><ul><ul><li>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. </li></ul></ul>
  5. 5. Mood Disorder: Depression <ul><li>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. </li></ul><ul><li>Patients with elevated mood demonstrate expansiveness, flight of ideas, decreased sleep, and grandiose ideas. </li></ul><ul><li>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. </li></ul><ul><li>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). </li></ul><ul><li>  These disorders virtually always result in  impaired interersonal, social, and occupational functioning </li></ul>
  6. 6. DSM-IV-TR Criteria for Major Depressive Episode Table 15.1-5-6 <ul><li>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 </li></ul><ul><ul><li>(1) depressed mood or </li></ul></ul><ul><ul><li>(2) loss of either loss of interest or pleasure. </li></ul></ul>
  7. 7. DSM-IV-TR Criteria for Major Depressive Episode <ul><li>Note: </li></ul><ul><ul><li>Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations </li></ul></ul><ul><ul><li>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) </li></ul></ul>
  8. 8. DSM-IV-TR Criteria for Major Depressive Episode <ul><li>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) </li></ul><ul><li>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. </li></ul><ul><li>Note </li></ul><ul><li>  In children, consider failure to make expectedIn children, consider failure to make expected weight gains. </li></ul>
  9. 9. DSM-IV-TR Criteria for Major Depressive Episode <ul><li>insomnia or hypersomnia nearly every day </li></ul><ul><li>psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) </li></ul>
  10. 10. DSM-IV-TR Criteria for Major Depressive Episode <ul><li>fatigue or loss of energy nearly everyday </li></ul><ul><li>feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every (not merely self-reproach or guilt about being sick) </li></ul><ul><li>diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) </li></ul><ul><li>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. </li></ul>
  11. 11. Treatment <ul><li>Guarantee patient safety </li></ul><ul><li>Complete diagnostic evaluation of the patient </li></ul><ul><li>Treatment plan that addresses: </li></ul><ul><ul><li>Immediate symptoms </li></ul></ul><ul><ul><li>Patient ’s prospective well-being </li></ul></ul>
  12. 12. Pharmacotherapy <ul><li>Once a diagnosis has been established a pharmacological treatment strategy can be formulated </li></ul><ul><li>Objective: </li></ul><ul><ul><li>Symptom remission not just reduction </li></ul></ul>
  13. 13. Pharmacotherapy <ul><li>Major depressive disorder </li></ul><ul><li>Most antidepressants have a lag period of 10 days to approximately 4 weeks before a therapeutic response is noted </li></ul><ul><li>Increasing dose will not shorten this period, it will increase the incidence of adverse reactions </li></ul>
  14. 14. Pharmacotherapy <ul><li>Antidepressants </li></ul><ul><ul><li>3 main classes </li></ul></ul><ul><ul><ul><li>Selective serotonin reuptake inhibitors (SSRIs) </li></ul></ul></ul><ul><ul><ul><li>Tricyclic Antidepressants ( Tas) </li></ul></ul></ul><ul><ul><ul><li>Mono amine oxidase Inhibitors (MAOIs) </li></ul></ul></ul><ul><ul><li>All three classes work differently but all change brain chemistry to improve neurotransmission. </li></ul></ul>
  15. 15. Pharmacotherapy <ul><li>Therapeutic response </li></ul><ul><ul><li>Not all patients respond the same way to a medication </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Similar positive responses to drug therapy can be obtained by augmenting the original drug with a drug of a different class. </li></ul></ul>
  16. 16. SSRIs <ul><li>SSRIs are the first choice in treating depression </li></ul><ul><ul><li>They are preferred over TAs and MAOIs </li></ul></ul><ul><ul><ul><li>Less damaging to the heart </li></ul></ul></ul><ul><ul><ul><li>Minimal anticholinergic effects </li></ul></ul></ul><ul><ul><ul><li>Minimal hypotensive effects </li></ul></ul></ul><ul><ul><li>Fluoxetin (Prozac) 1987, became the first SSRI approved by the FDA for use as antidepressant. </li></ul></ul><ul><ul><li>Currently sertraline (Zoloft) is one of the most widely used antidepressants in the United States. </li></ul></ul><ul><ul><li>Readings- Chapter 36.29 pg 1083-1090 </li></ul></ul><ul><ul><li>See tables 36.29-1 and 36.29-2 </li></ul></ul>
  17. 17. SSRIs <ul><ul><li>Pharmacokinetics </li></ul></ul><ul><ul><ul><li>SSRIs have a broad range of serum half- lives </li></ul></ul></ul><ul><ul><ul><ul><li>Fluoxetine has the longest half-life- 4 to 6 days; its active metabolite has a half-life of 7-9 days </li></ul></ul></ul></ul><ul><ul><ul><li>SSRIs are well absorbed, peak effects range from 3 to 8 hours </li></ul></ul></ul><ul><ul><ul><li>All SSRIs are metabolized by the liver by cytochrome P450 (CYP) enzymes </li></ul></ul></ul><ul><ul><ul><li>Most interaction activities are related to inhibition of metabolism of coadministered medications. </li></ul></ul></ul>
  18. 18. Pharmacodynamics <ul><li>SSRIs: </li></ul><ul><ul><li>Exert their therapeutic effects through 5HT reuptake inhibition </li></ul></ul><ul><ul><li>Higher dosages do not increase antidepressant efficacy- may increase incidence of adverse effects </li></ul></ul><ul><ul><li>Citalopram and escitalopram are the most selective of the SSRIs </li></ul></ul><ul><ul><li>Other SSRIs also have actions on norepinephrine and dopamine receptors, causing reuptake inhibition. </li></ul></ul>
  19. 19. Therapeutic Indication <ul><li>In the US all SSRIs, except fluvoxamine have FDA approval for use in the treatment of depression. </li></ul><ul><li>Studies have found that antidepressants with serotonin-norepinephrine activity (MAOIs TCAs) produce higher rates of remission than SSRIs </li></ul><ul><ul><li>Venlafaxine & mirtazapine </li></ul></ul><ul><li>In the past SSRIs have been link to a slight increase in suicide ideation. However the relation remains unclear </li></ul><ul><li>A noted increase in anxiety and agitation has been seen in some patients </li></ul>
  20. 20. Pregnancy and Postpartum Depression <ul><li>Postpartum depression affects a small percentage of mothers </li></ul><ul><li>68 to 100 percent relapse in pregnant patients that discontinue therapy </li></ul><ul><li>Evidence suggests increased rates of special care nursery admission after delivery for children of mothers on SSRIs </li></ul><ul><li>SSRIs are secreted in breast milk; however [plasma] levels are usually very low in mothers that are breast feeding. </li></ul>
  21. 21. Depression in the Elderly <ul><li>SSRIs are safe and well tolerated when used in the elderly and medically ill </li></ul><ul><ul><li>Little or no cardiotoxic effects </li></ul></ul><ul><ul><li>Little or no anticholinergic effects </li></ul></ul><ul><ul><li>Little or no antihistaminergic effects </li></ul></ul><ul><ul><li>Little or no alpha-adrenergic adverse effects </li></ul></ul>
  22. 22. Depression in Children <ul><li>Only fluoxetine has FDA approval for use as an antidepressant in this population </li></ul><ul><li>Reports indicate that SSRIs can increase suicidal and violent thoughts or actions in depressed children </li></ul><ul><li>Children treated with SSRIs require close monitoring </li></ul>
  23. 23. Precautions and Adverse Reactions <ul><li>Sexual dysfunction </li></ul><ul><ul><li>Most common adverse effect of SSRIs </li></ul></ul><ul><li>GI </li></ul><ul><ul><li>Very common, mediated largely through the effects on the serotonin 5HT receptors </li></ul></ul><ul><ul><ul><li>Nausea </li></ul></ul></ul><ul><ul><ul><li>Diarrhea </li></ul></ul></ul><ul><ul><ul><li>Anorexia </li></ul></ul></ul><ul><ul><ul><li>Vomiting </li></ul></ul></ul><ul><ul><ul><li>Flatulence </li></ul></ul></ul><ul><ul><ul><li>Dyspepsia </li></ul></ul></ul>
  24. 24. Precautions and Adverse Reactions <ul><li>Headaches </li></ul><ul><ul><li>18 to 20 percent of cases </li></ul></ul><ul><li>CNS adverse effects </li></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><ul><li>First few weeks </li></ul></ul></ul><ul><ul><li>Insomnia & Sedation </li></ul></ul><ul><ul><ul><li>Improved sleeping resulting from treatment of depression and anxiety </li></ul></ul></ul><ul><ul><ul><li>Vivid dreams </li></ul></ul></ul>
  25. 25. Precautions and Adverse Reactions <ul><li>CNS adverse effects (cont.) </li></ul><ul><ul><li>Emotional blunting </li></ul></ul><ul><ul><ul><li>Inability to express emotions </li></ul></ul></ul><ul><ul><li>Yawning </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><ul><li>0.1 to 0.2 percent </li></ul></ul></ul><ul><ul><li>Extrapyramidal Symptoms </li></ul></ul><ul><li>Anticholinergic Effects </li></ul><ul><ul><li>Paroxetine </li></ul></ul><ul><ul><ul><li>Mild anticholinergic effects </li></ul></ul></ul><ul><li>Hematologic Adverse effects </li></ul><ul><ul><li>Can cause functional impairment of platelet aggregation </li></ul></ul><ul><ul><ul><li>Easy bruising, prolonged bleeding </li></ul></ul></ul><ul><ul><li>Special monitoring suggested for patients on SSRIs and anticoagulants </li></ul></ul>
  26. 26. Precautions and Adverse Reactions <ul><li>Electrolyte and Glucose Disturbances </li></ul><ul><ul><li>SSRIs may decrease [glucose] </li></ul></ul><ul><ul><ul><li>Careful monitoring for diabetic patients suggested </li></ul></ul></ul><ul><li>Endocrine and Allergic Reactions </li></ul><ul><ul><li>SSRIs can decrease prolactin levels </li></ul></ul><ul><ul><ul><li>Mammoplasia and galactorrhea in both men and women </li></ul></ul></ul><ul><ul><ul><li>Various types of rashes- 4% of patients </li></ul></ul></ul><ul><li>Serotonin syndrome </li></ul><ul><ul><li>Concurrent administration of an SSRI with MAOI, L-Tryptophan or lithium can raise plasma [serotonin] to toxic levels </li></ul></ul>
  27. 27. Precautions and Adverse Reactions <ul><li>Sweating </li></ul><ul><ul><li>Experienced by some patients while on SSRIs </li></ul></ul><ul><li>SSRI withdrawal </li></ul><ul><ul><li>May exhibit withdrawal symptoms upon sudden discontinuation </li></ul></ul><ul><ul><li>Drug interactions see table 36.29-3 </li></ul></ul>
  28. 31. Suicide <ul><li>Primary emergence for the mental health professional </li></ul><ul><li>Major public health problem </li></ul><ul><li>Over 30,000 persons commit suicide each year in the US </li></ul><ul><li>More than 600,000 attempt suicide </li></ul>
  29. 32. Suicide: Risk Factors <ul><li>Gender </li></ul><ul><ul><li>MORE COMMON IN MALE </li></ul></ul><ul><li>Age </li></ul><ul><ul><li>15-44 </li></ul></ul><ul><li>Race </li></ul><ul><ul><li>More common among white males </li></ul></ul><ul><li>Religion </li></ul><ul><ul><li>Higher in Protestants and Jews than Roman Catholics </li></ul></ul><ul><li>Marital Status </li></ul><ul><ul><li>Single, never married persons are twice more likely to comit suicide than married persons. </li></ul></ul><ul><ul><li>Divorce increases the likelihood of suicide </li></ul></ul><ul><ul><li>Widows also have a higher rate </li></ul></ul>
  30. 33. Suicide: Risk Factors cont. <ul><li>Social Status </li></ul><ul><ul><li>The higher the person ’s social status, the higher the incidence </li></ul></ul><ul><ul><li>A fall in social status also increases the risk of suicide </li></ul></ul><ul><li>Occupations </li></ul><ul><ul><li>Both males and female physicians in the US have increase rates of suicide </li></ul></ul><ul><li>Climate </li></ul><ul><ul><li>No significant data indicates a correlation with climate and suicide. </li></ul></ul><ul><li>Physical Health </li></ul><ul><ul><li>The relation of physical health and illness to suicide is significant </li></ul></ul><ul><li>Mental Health </li></ul><ul><ul><li>Almost 95% of all persons who commit suicide have a diagnosed mental illness. </li></ul></ul>
  31. 34. Suicide: Risk Factors cont. <ul><li>Psychiatric Patients </li></ul><ul><ul><li>Psychiatric patients ’ risk for suicide is 3 to 12 times that of non psychiatric patients. </li></ul></ul><ul><ul><ul><li>Depressive disorders </li></ul></ul></ul><ul><ul><ul><li>Schizophrenia </li></ul></ul></ul><ul><ul><ul><li>Alcohol Dependence </li></ul></ul></ul><ul><ul><ul><li>Other Substance dependence </li></ul></ul></ul><ul><ul><ul><li>Personality Disorders </li></ul></ul></ul>
  32. 35. Suicide: Treatment <ul><li>Decision to hospitalize a patient with suicidal ideation depends on: </li></ul><ul><ul><li>Severity of depression </li></ul></ul><ul><ul><li>Severity of suicidal ideation </li></ul></ul><ul><ul><li>Patient ’s family’s coping ability </li></ul></ul><ul><ul><li>Patient ’s living situation </li></ul></ul><ul><ul><li>Availability of social support </li></ul></ul><ul><ul><li>Absence or presence of risk factors for suicide </li></ul></ul>
  33. 36. Suicide: Pharmacotherapy <ul><li>Patients hospitalized can receive medication for underlying diagnoses, leading to suicide ideations or attempts: </li></ul><ul><ul><li>Antidepressants </li></ul></ul><ul><ul><li>Antipsychotics </li></ul></ul><ul><ul><li>When patients present signs of both, medications like risperidone (Risperdal) that have both antipsychotic and antidepressant effects are very useful. </li></ul></ul><ul><ul><li>Vigorous treatment should be initiated depending onunderlying disorder. </li></ul></ul><ul><ul><li>Supportive psychotherapy is also indicated. </li></ul></ul><ul><li>ECT may be necessary for severely depressed patients </li></ul>