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Depression

Types:
1. Major depressive disorder:
  1. Affects 5-10% of adults.
    1. Majority of patients found in mainstream society.
      1. Recognition is a collaborative effort
2. Situational depression
  1. Result of circumstances in person's life.
3. Dysthymic disorder
  1. Severe depression that may last several years.
    1. Person does not "feel well".
      1. May not function normally
4. Postpartum depression
  1. Up to 80% of women experience it.
    1. Caused by hormonal changes.
    2. Prevalent enough that some state agencies mandate all new mothers receive info about mood shifts
5. Seasonal effective disorder
  1. Enhanced release of melatonin r/t lower lvls of natural light.
    1. May be relieved w/light therapy
6. Psychotic depression
  1. Expression of intense mood shifts and unusual behaviors.
    1. Depressive signs, loss of contact with reality, hallucinations, delusions, and disorganized speech.
Assessment & treatment
1. Corticosteroids, levodopa, and oral contraceptives can cause similar symptoms to depression
  1. Rule out this possibility in health exam
2. Medical and neurologic disorders can also cause depressive symptoms.
  1. This too
3. Ask about alcohol & drug use, family history.
4. Therapy:
  1. Interpersonal:
    1. Focuses on pt/ disturbed relationships
  2. Cognitive-behavioral therapy:
    1. Help pt, change negative styles of thought & behavior.
  3. Psychodynamic:
    1. Focus on resolving pt. internal conflict.
      1. Postponed until symptoms are significantly improved
5. Electroconvulsive therapy is useful when therapy fails.
  1. Over 70% show improvement
6. Transcranial magnetic stimulation may be an effective somatic treatment.
  1. Surgical implant that does not effect memory, require general anesthetic, and is helpful w/o overt risk of generalized seizures
Antidepressants
1. Depression & anxiety are caused by similar neurotransmitter dysfunction.
  1. Can also treat some pain
    1. Closely monitor for warning signs of suicide, especially at beginning of treatment.
      1. Children to young adults are at greater risk.
      2. Also monitor for anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania.
2. Exerts effects through action on norepinephrine, serotonin, and dopamine.
  1. Will either block breakdown of norepinephrine or slow reuptake of serotonin and norepinephrine
3. Selective serotonin repuptake inhibitors (SSRIs)
  1. Same efficacy as MAOIs and TCAs
    1. Advantage: greater safety profile, less sympathomimetic and anticholinergic effects, no cardiotoxicity.
      1. Makes presynaptic neurons less sensitive to serotonin, but postsynaptic more sensitive
        All drugs have equal efficacy and similar side effects.
        Most common side effect is impotence.
        Serotonin syndrome can result when combining an SSRi w/ an MAOI, a TCA, lithium, or any number of drugs
        Signs include confusion, anxiety, restlesness, hypertension, tremors, sweating, hyperpyrexia, or ataxia.
  2. Serotonin is found in high concentrations in hypothalamus, limbic system , medulla, and spinal cord
    1. Functions in cycling btwn REM and NREM sleep, pain perception & emotion
      1. Inadequate amounts cause depression
  3. Atypical antidepressants
    1. Serotonin-norepinephrine reuptake inhibitors:
      1. Includes duloxetine (Cymbalta) and venlafaxine (Effexor)
        In many cases dopamine is also affected.
        Duloxetine is also approved for GAD and neuropathic pain
        Venlafaxine is also approved for GAD.
    2. Bupropion (Wellbutrin)
      1. Reuptakes serotonin and affects activity of norepinephrine and dopamine
        Contraindicated in pt. w/seizure disorder
    3. Mirtazapine (Remeron)
      1. Blocks presynaptic serotonin and norepinephrine receptors
    4. Nefazodone
      1. Similar to mirtazapine
        Causes minimal CV effects, fewer anticholinergic effects, less sedation, and less sexual dysfunction, but does cause hepatotoxicity
    5. Trazodone (Oleptro)
      1. Used to treat insomnia b/c high levels are needed for depression, and that causes sedation
    6. Tricyclic antidepressnats
      1. Inhibits presynaptic reuptake of norepinephrine and serotonin
        Safer than MAOIs, but side effects still include orthostatic hypotension, cardiac dysrhythmia, dry mouth, constipation, blurred vision, and tachycardia.
        Most have a long half life, increasing side effect risk.
        Significant interactions w/ CNS depressants, sympathomimetics, anticolinergics, and MAOIs.
        Clomipramine (Anafranil) is used for OCD
        Doexpin (Sinequan) is for GAD, neuropathic pain, and fibromyalgia
        Some are used off label for panic disorder and social anxiety. Can be used for childhood bed wetting too.
      2. Monoamine oxidase inhibitors
        Decreases effectiveness of MAO, thus limiting breakdown of norepinephrine, epinephrine, dopamine, and serotonin
        B/c of interactions , hepatotoxicity, and safer meds, these are reserved for pt. unresponsive to conventional treatment.
        Common side effects are orthostatic hypotension, headache, insomnia, and diarrhea.
        Hypertensive crisis can occur w/antidepressants and sympathomimetic drugs.
        Serotonin syndrome can occur when combined w/SSRIs
        Severe hypotension when combined w/antihypertensives
        Potentiates hypoglycemic effects of insulin &oral antidiabetic drugs
        When taken w/meperidine, dextromethorphan, or TCAs, hyperpyrexia can occur
        Hypertensive crisis can occur when combined w/foods containing tyramine.
        Tyramine is degraded by MAO in intestines, but if MAO is inhibited, it enters the bloodstream in high concentrations and displaces norepinephrine within presynaptic nerve terminals.
        Results in sudden release of norepinephrine.
        Occipital headache, stiff neck, flushing, palpations, diaphoresis, and nausea are symptoms.
        Mi and stroke can happen.
        Calcium channel blockers can be given as an antidote.

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Depression

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