Depression psychiatry

psychiatric al disorder depression in medicine.

1. DEPRESSION Depression is a affective disorder. Affective disorders : mental illnesses characterized by pathological changes in mood. Depression : pathologically depressed mood

2. DEFIN I TION DEPRESSION : Common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self- worth, disturbed sleep or appetite, low energy, and poor concentration.

3. TYPES OF DEPRESSION Major depressive disorder : recurrence of long episodes of low moods, or one extended episode that seems to be ‘never-ending. Atypical depression Post partum depression Catatonic depression Seasonal affective disorder Melancholic depression

4. Dysthymic depression lasts a long time but involves less severe symptoms. lead a normal life, but we may not be functioning well or feeling good Situational depression Psychotic depression Endogenous depression

5. MAJOR DEPRESSIVE DISORDER aka unipolar depression lifetime prevalence: up to 21% in women 13% in men typical age of onset: 20s, but can occur at any time

6. SYMPTOMS OF MDD Feelings of sadness, tearfulness, emptiness or hopelessness Angry outbursts, irritability or frustration, even over small matters Loss of interest or pleasure in most or all normal activities, such as sex, hobbies or sports Sleep disturbances, including insomnia or sleeping too much Tiredness and lack of energy, so even small tasks take extra effort Reduced appetite and weight loss or increased cravings for food and weight gain Anxiety, agitation or restlessness Slowed thinking, speaking or body movements Feelings of worthlessness or guilt, fixating on past failures or self-blame Trouble thinking, concentrating, making decisions and remembering things Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts or suicide Unexplained physical problems, such as back pain or headaches

7. ATYPICAL DEPRESSION Described in DSM-IV Depression that shares many of the typical symptoms of the major depression or   dysthymia B ut is characterized by improved mood in response to positive events. It also features significant weight gain or an increased appetite,  hypersomnia, a heavy sensation in the limbs, and interpersonal rejection sensitivity that results in significant social or occupational impairment

8. POSTPARTUM DEPRESSION A lso called  P ostnatal depression Associated with  childbirth Can affect both sexes Symptoms may include: extreme sadness, low energy,  anxiety , crying episodes, irritability, and changes in sleeping or eating patterns Onset is typically between one week and one month following childbirth PPD can also negatively affect the newborn child

9. CATATONIC DEPRESSION Catatonic depression affects the individual’s motor skills Can be caused by other underlying mental health disorders, such as  schizophrenia , mood disorders, and post-traumatic stress disorder People with catatonia remain still and do not respond to any events/things around them There are three types of catatonia: akinetic , excited and malignant catatonia Akinetic catatonia is the most commonly observed in people with catatonic depression M alignant catatonia can be dangerous, causing severe health effects

10. SIGNS AND SYMPTOMS Automatic obedience  – The patient automatically obeys all instructions given by the doctor Ambitendency  – The patient alternates between cooperating with the doctor’s instructions and resisting them Aversion  – The patient turns away when he or she is being spoken to Echopraxia   – The patient imitates the activities of the person speaking with him or her. Excitement  – The patient engages in excessive and purposeless action that is not driven by outside stimuli Negativism  – The person is always having negative thoughts and feels sad every day Stupor  – This is one of the common signs of catatonia. It is characterized by a lack of mobility and speech Posturing  – The person remains in the same posture for a long period of time Mutism  – The person is verbally unresponsive and refuses to speak Staring  – The individual’s eye is fixed on a particular space and open for long periods of time .

11. SEASONAL DEPRESSION More than just "the winter blues" S easonal depression is often called seasonal affective disorder ( SAD) O ccurs at the same time each year Linked to reduced exposure to sunlight during the shorter autumn and winter days (production of Melatonin, Serotonin and Circadian rhythm) Symptoms: A persistent low mood A loss of pleasure or interest in normal everyday activities I rritability F eelings of despair, guilt and worthlessness F eeling lethargic (lacking in energy) and sleepy during the day S leeping for longer than normal and finding it hard to wake up C raving   carbohydrates and gaining weight

12. MELANCHOLIC DEPRESSION Melancholic depression, or depression with melancholic features Is a  DSM-IV and   DSM-5 subtype of clinical depression Signs and Symptoms Requiring at least one of the following symptoms: Anhedonia Lack of mood reactivity And at least three of the following: Depression that is subjectively different from grief or loss Severe weight loss or loss of appetite Psychomotor agitation or retardation Early morning awakening Guilt that is excessive Worse mood in the morning

13. Double Depression Dysthymic disorder with episodes of major depression Prognosis more negative

14. EPIDEMIOLOGY Globally more than 350 million people of all ages suffer from depression. (WHO) For the age group 15-44 major depression is the leading cause of disability in the U.S. Women are nearly twice as likely to suffer from a major depressive disorder than men are. With age the symptoms of depression become even more severe. About thirty percent of people with depressive illnesses attempt suicide.

15. ETIOLOGY Genetic cause Environmental factors Biochemical factors : Biochemical theory of depression postulates a deficiency of neurotransmitters in certain areas of the brain (noradrenaline, serotonin, and dopamine). Dopaminergic activity : reduced in case of depression, over activity in mania. Endocrine factors - h y p o t h y r o i dis m , cus h i n g ’ s s y n d r o m e etc

16. Abuse of Drugs or Alcohol Hormone Level Changes P h ys i c a l ill n ess and si d e e f fe c ts of m edic a ti o ns DRUGS Analgesics Antidepressants Antihypertensives Anticonvulsants Benzodiazipine withdrawal Antipsychotics

17. PH Y SICAL ILL N ESS Viral illness Carcinoma Neurological disorders Thyroid disease Multiple sclerosis Pernicious anaemia Diabetes Systemic lupus erythematosus Addison’s disease

18. PATHOPHYSIOLOGY The Bioge n ic Amine Hy p oth e sis The Receptor Sensitivity Hypothesis The Serotonin-only Hypothesis The Permissive Hypothesis The Electrolyte Membrane Hypothesis The Neuroendocrine Hypothesis

19. The Biog e nic Amine Hy p oth e sis - caused by a deficiency of monoamines, particularly noradrenaline and serotonin. cannot explain the delay in time of onset of clinical relief of depression of up to 6-8 weeks. The Receptor Sensitivity Hypothesis depression is the result of a pathological alteration (supersensitivity and up-regulation) in receptor sites. - TCAs or MAOIs causes desensitization (the uncoupling of receptor sites) and possibly down- regulation (a decrease in the number of receptor sites).

20. The Serotonin-only Hypothesis emphasizes the role of serotonin in depression and downplays noradrenaline. But the serotonin-only theory has shortcomings: it does not explain why there is a delay in onset of clinical relief it does not explain the role of NA in depression.

21. The Permissive Hypothesis the control of emotional behavior results from a balance between noradrenaline and serotonin. If serotonin and noradrenaline falls to abnormally low levels, the patient becomes depressed. If the level of serotonin falls and the level of noradrenaline becomes abnormally high, the patient becomes manic.

22. The Electrolyte Membrane Hypothesis hypocalcemia may be associated with mania. hypercalcemia is associated with depression. The Neuroendocrine Hypothesis - pathological mood states are explained or contributed to by altered endocrine function.

23. CLINICAL MANIFESTATIONS DEPRESSIONS Thinking is pessimistic and in some cases suicidal. In severe cases psychotic symptoms such as hallucinations or delusions may be present. Insomnia or hypersomnia, libido, weight loss, loss of appetite. Intellectual or cognitive symptoms include a decreased ability to concentrate, slowed thinking, & a poor memory for recent events.

24. DIAGNOSIS ICD 10 Diagnostic criteria for a depressive episode (WHO) USUAL SYMPTOMS Depressed mood. Loss of interest and enjoyment. Reduced energy leading to increased fatiguability and diminished activity.

25. CO M MO N SYMPTOMS Reduced concentration and attention. Reduced self esteem and self confidence. Ideas of guilt and unworthiness. Bleak and pessimistic views of future . Ideas or acts of self harm or suicide. Disturbed sleep. Diminished appetite.

26. MILD DEP R E S SIVE EPI S ODE For at least 2 weeks, at least two of the usual symptoms of a depressive episode plus at least two common symptoms. MODERATE DEPRESSIVE EPISODE For at least 2 weeks, at least two or three of the usual symptoms of a depressive episode plus at least three of the common symtoms.

27. SEVERE DEPRESSIVE EPISODE For at least 2 weeks all three of the usual symptoms of a depressive episode plus at least 4 of the co mm on sy m pt o m s so m e of w hich sh o uld be of severe intensity.

28. INVESTIGATIONS RATING SCALES Beck depression inventory Hamilton depression rating scale DEXAMETHASONE SUPPRESSION TEST

29. TREA T MEN T ANTIDEPRESSANTS 1 . MAO inhibitors: Irreversible: Isocarboxazid, Iproniazid, Phenelzine and Tranylcypromine. Reversible: Moclobemide and Clorgyline. 2. Tricyclic antidepressants (TCAs) NA and 5 HT reuptake inhibitors : Imipramine, Amitryptiline, Doxepin, Dothiepin and Clomipramine. NA reuptake inhibitors : Desimipramine, Nor t r y p t y l i n e , A m o x api n e.

30. 3. Selective Serotonin reuptake inhibitors: Fluoxetine, Fluvoxamine, Sertraline and Citalopram 4. Atypical antidepressants: Trazodone, Mianserin, Mirtazapine, Venlafaxine, Duloxetine, Bupropion and Tianeptine

31. MAO Inhibitors Drugs act by increasing the local availability of NA or 5 HT. MAO is a Mitochondrial Enzyme involved in Oxidative deamination of these amines. MAO-A: Peripheral nerve endings, Intestine and Placenta (5-HT and NA). MAO-B: Brain and in Platelets (Dopamine). Selective MAO-A inhibitors (RIMA) have anti d epres s ant p r o p erty (eg:M o clo b e m i de ).

32. Side effects : postural hypotension, weight gain, atropine like effects and CNS stimulation. Severe hypertensive response to tyramine containing foods-cheese reaction Drug interaction : Ephedrine, Reserpine .

33. T CAs NA, 5 HT and Dopamine are present in Nerve endings Normally, there are reuptake mechanism and termination of action. TCAs inhibit reuptake and make more monoamines available for action. In most TCA, other receptors (incl. those outside the CNS) are also affected: blockade of H1-receptor, Alpha-receptors, M-receptors.

34. SSRIs First line drug in depression. Relatively safe and better patient acceptability. Some patients not responding to TCAs may respond with SSRIs. SSRIs inhibit the reuptake mechanism and make more 5 HT available for action.

35. Relative advantages: No sedation, so no cognitive or psychomotor function interference No anicholinergic effects No alpha-blocking action, so no postural hypotension and suits for elderly No seizure induction No arrhythmia Drawbacks: Nausea is common Interfere with ejaculation Insomnia, dyskinesia, headache and diarrhoea Impairment of platelet function – epistaxis

36. SSRIs – Pharmacokinetic comparison

37. Atypical antidepressants 1. Trazodone: Weak 5-HT uptake block, α – block, 5-HT2 antagonist No arrhythmia No seizure ADRs: Postural Hypotension 2. Venlafaxine: SNRI (Serotonin and NA uptake inhibitor) Fast in action No cholinergic, adrenergic and histaminic interference Raising of BP

38. 3 . Mianserin Not inhibiting either NA or 5 HT uptake, but blocks presynaptic alpha-2 receptors- increase release of NA in brain. ADR : Blood dyscrasias, liver dysfunction. 4. Bupropion Inhibitor of DA and NA uptake (NDRI) Non-sedative but excitant property Used in depression and cessation of smoking Seizure may precipitated

39. Serotonin Syndrom A group of symptoms that may occur with the use of certain  serotonergic medications or  drugs The degree of symptoms can range from mild to severe, including a potentiality of death Symptoms in mild cases include high blood pressure and a fast heart rate; usually without a  fever Symptoms in moderate cases include: fever, agitation ,  increased reflexes , tremor,  sweating , dilated pupils , and  diarrhea In severe cases body temperature can increase to greater than 41.1  °C. Complications may include  seizures and  extensive muscle breakdown, kidney failure and unconsciousness

40. Causes of Serotonin Syndrom Selective serotonin reuptake inhibitors Serotonin and norepinephrine reuptake inhibitors Bupropion   an antidepressant and tobacco-addiction medication Tricyclic antidepressants Monoamine oxidase inhibitors Anti-migraine medications,  such as carbamazepine, valproic acid and triptans Pain medications,  such as opioid pain medications including codeine, fentanyl, oxycodone Lithium   a mood stabilizer Illicit drugs,  including LSD, ecstasy, cocaine and amphetamines Herbal supplements,  including St. John's wort, ginseng and nutmeg Over-the-counter cough and cold medications  containing dextromethorphan Anti-nausea medications  such as granisetron , metoclopramide and etc. Linezolid   an antibiotic Ritonavir   an anti-retroviral medication used to treat HIV

41. Treatment of Serotonin Syndrom Depending on your symptoms, you may receive the following treatments : Muscle relaxants.  Benzodiazepines, they can help control agitation, seizures and muscle stiffness. Serotonin-production blocking agents Oxygen and intravenous (IV) fluids.  Breathing oxygen through a mask helps maintain normal oxygen levels in your blood, and IV fluids are used to treat dehydration and fever. Drugs that control heart rate and blood pressure.   A breathing tube and machine and medication to paralyze your muscles.   You may need this treatment if you have a high fever.

42. NON – PHARMACOLO G IC THERAPY LIFESTYLE CHANGES Stress reduction Social support Sleep PSYCHOTHERAPY Cognitive behavioral therapy Interpersonal therapy Psychodynamic therapy

43. Comparing Treatments Studies compare CBT and IPT to antidepressant meds and other control conditions results CBT, IPT, and meds are equally effective CBT, IPT, and meds are more effective than placebo conditions brief psychodynamic treatments other control conditions 50-70% of people benefit from treatment to a significant extent, compared to 30% in placebo or control conditions

44. Combined Treatments Meds work more quickly Psychosocial treatments: Increase long-range social functioning Prevent relapse

45. ELECTROCONVULSIVE THERAPY – ECT Safe & effective disorder for all subtypes of major depressive disorder. ADR : Cognitive dysfunction, cardiovascular dysfunction, prolonged apnoea etc.

46. CONCLUSION Affective disorders remain one of the most commonly occurring mental illnesses in adults. It is often undiagnosed and untreated. Both pharmacological and nonpharmacological i n terve n ti o ns a c ts as cor n erst o ne in t h e treat m ent of affective disorders. Pharmacist plays an important role in accomplishing these treatment goals.