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DSM-IV Criteria for Major Depression
> or = 5 symptoms (SIG E CAPS) PLUS depressed mood or anhedonia, causing sign.dysfunction for at least 2 weeks
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DSM-IV Criteria for Minor Depression
2-4 symptoms PLUS depressed mood, anhedonia causing sign.dysfunction, for at least 2 weeks
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Depression Criteria (SIG E CAPS) acronym
- S: suicidal thoughts
- I: interest decrease in almost all activities
- G: guilt; worthlessness/hopelessness
E: energy decrease
- C: concentration problems
- A: appetite/weight change
- P: psychomotor agitation/retardation
- S: sleep disturbance/decreased sexual desire
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DSM-IV Criteria for Dysthymia
3-4 sx PLUS depressed mood, causing sign. dysfunction for > or = 2 years
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Most common presenting symptoms of depression
- Fatigue
- sleep disturbances
- pain
- anxiety, irritability
- dysphoric (loss of interest, social withdrawal, irritability)
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Women and depression
women are twice as likely to suffer from mood disorders, eating disorders, more likely to attempt suicide
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Periods of increased risk of depression in women
premenstrual phase, immediate postpartum period, perimenopause (5 yrs before & 5 years after)
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Risk factors for depression in women
- - use of O.C. (especially high in progesterone)
- - infertility treatments
- - persistent psychosocial stressors (loss of job)
- - threat or loss of social support system
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Criteria for premenstrual dysphoric disorder
- - onset 1-2 weeks before menstrual flow
- - impaired fx or interpersonal relationships
- - occurs in 2-9%
- - age of onset usually late 20's, can worsen w/ age
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Postpartum Blues
- Incidence: 60-70% of post-partum women
- Peak: 3-7 days, lasts < 2 weeks
- Risk Factors: primiparous, hx of PMS
- Tx: reassurance to pt., educate family
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Postpartum depression
- Occurs: 8-15% of women, >20% of adolescent mothers
- Onset: 60-70% within 6 weeks
- Symptoms: excessive worry, somatic sx in excess or w/o physical cause
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Late-life depression: Prevalence rates
Highest rates in LTC sites, stroke pts., then MI pts.
Lowest rates in community elderly then the general population
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Differentiating Depression from Grief (Major Depression)
Guilt & self blame
> 6 months duration
May be incapacitated
May be suicidal
Unremitting
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Differentiating Depression from Grief (Grief reaction)
guilt & self blame
< 6 months duration
can usually function
Usually NOT suicidal
Exacerbations/remittance
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When to consider pathological grief reaction...
previous dx of depression
lasts longer than 6-12mos
- Results in:
- social withdrawal
- functional decline
MEN ARE AT HIGHER RISK OF PATHOLOGICAL GRIEF REACTION than women, following a spouse's death
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Subsyndromal depression
pt. has clinically significant depressive symptoms but does not meet criteria by time, duration, quantity or severity criteria.
Use of psychotherapy may benefit these patients.
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Distinctive diagnostic features of depression in elderly
- - chronic pain
- - anxiety
- - memory impairment: forgetful
- - motor slowing
- - excessive functional disability
- - Men: anger, apathy, anhedonia w/o sadness
- - women: somatic sx, sadness
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U.S.P.S.T.F. Recommendations for Screening for Depression
Screening tool to be filled out while waiting to be seen.
OR
Clinicians evaluate pts. when the clinical presentation triggers the suspicion of depression.
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USPSTF Depression Screening questions
1. Over the past 2 weeks (month), have you ever felt down, depressed, or hopeless?
2. Over the past 2 weeks (month), have you felt little pleasure or interest in doing things?
Sensitivity 96% Specificity 57%
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Time course of clinical response to antidepressant therapy
2 weeks: initial response
4 weeks: substantial response
8-12 weeks: maximal benefit
Maintenance:
9-12 months minimum tx at full dosage
Relapse risk up to 70% if early D/C
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When do pts. often stop taking antidepressant meds?
- 1 month: 72% compliant
- 3 months: 56% compliant
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Antidepressant use and weight gain (long-term)
Weight loss: Buproprion, fluoxetine
Weight gain: citalopram, mirtazapine, nefazodone, paroxetine (worst), sertraline
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SSRI Withdrawal Syndrome
Most common sx: dizziness, irritability, vivid dreams, lethargy, panic-like attacks
- - paroxetine (20% of the time)
- - fluoxetine (0% of the time for withdrawal)
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Recurrence rates of depression
1 year: 33%
2 years: 50%
8 years: 75%
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Long-term maintenance Rx of depression
Advisable after 2 episodes of MDD who:
- - have 1st deg. family hx of recurrent MDD
- - hx of recurrence w/in 1 year after previous effective rx d/c'd
- - onset of MDD < age 20
- - severe, sudden or life-threatening in both episode w/in past 3 years.
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When to refer...
Pts. with severe symptoms
- - suicidal tendencies/hx of attempts
- - bipolar disorder
- - atypical disorder
- - psychotic depression
- - pts. who have had drug-drug reaction or who will need complex therapy
- - pts. who are tx resistant
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SSRI-induced dysfunction
changes in sexual response occur because of increased serotonin activity at the 5-HT2 receptor site causing:
- - loss of libido
- - delayed time to orgasm
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Strategies for the treatment of antidepressant-induced sexual dysfunction
- - baseline eval.
- - educate on S.E.
- - tolerance to the medication
- - switch antidepressant
- - drug holiday (d/c after thursday dose, restart Sunday by noon)
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