Major Depressive Disorder (MDD) - PDF

Major Depressive Disorder MDD  Introduction Individuals with major depressive disorder (MDD) Experience pervasive symptoms affecting mood, thinking, physical health, work, and relationships. Major depression is a common, seriously disabling, disor...

Major Depressive Disorder MDD  Introduction Individuals with major depressive disorder (MDD) Experience pervasive symptoms affecting mood, thinking, physical health, work, and relationships. Major depression is a common, seriously disabling, disorder nonresponsive to doing efforts to feel better. Suicide often results when MDD is inadequately diagnosed and treated. Epidemiology & Etiology The lifetime prevalence estimates for MDD are 16.2%. - Women are twice as likely as men to experience MDD. The average age of onset is in the mid-twenties. Interestingly, MDD appears to occur earlier in life in people born in more recent decades. According to the WHO, depression is: One of the leading cause of disability Fourth leading cause of the global burden of disease. Many patients with MDD have comorbid psychiatric disorders, especially anxiety and substance abuse disorders. Some individuals have only a single episode with full return to premorbid functioning, 50%-85% have recurrences. DSM-V Classification of Depressive Disorders Diagnostic and Statistical Manual of Mental Disorders Unipolar Bipolar AMERICAN PSYCHIATRIC ASSOCIATION Major depressive disorder Common: ✓ Sad, empty, or irritable mood. Persistent depressive disorder (dysthymia) ‫اكتئاب‬ ✓ Accompanied by somatic and cognitive changes. ‫يرافقه تغييرات جسدية ومعرفية‬ ✓ A significantly effect on the individual's capacity to function. ‫تأثير كبير على قدرة‬ ‫الفرد على أداء وظائفه‬ Premenstrual dysphoric disorder DSM-5 UPDATE Disease/medication- induced depressive disorder SUPPLEMENT TO DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FIFTH EDITION October 2017 AMERICAN PSYCHIATRIC ASSOCIATION DSM-5-TR* Update Supplement to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision September 2024 Previous updates: September 2023 Who's at risk of depression? There are certain situations and events that may increase your chance of becoming depressed: 1. People with a family history of depression 2. A history of abuse or trauma 3. Alcohol or drug abuse 4. Mental Health History The presence of other serious psychological or physical stressors such as divorce or death of a loved one ALCOHOL Pathophysiology The cause of MDD is unknown but is probably multifactorial. 1) Genetic predisposition 2) Psychological stressors 3) Underlying pathophysiology Pathophysiology 1) Genetics First-degree relatives of MDD patients are about three times more likely to develop MDD compared with controls. De Dina 2) Stress Socioeconomic stress Failure to achieve a desired or expected goal Marital-problems- separation, divorce Death of a loved one Physical illness, an accident, surgical operation or childbirth Occupational or financial loss Parental negligence Or loss of a parent  2) Stress - Major life stressors do not always cause depression. - Nevertheless, there is an undeniable association between life stressors and depression, and there appears to be a significant causative interaction between life stressors and genetic predisposition. - Acute stressors may precipitate depression. - Chronic stressors cause longer episodes and are more likely to lead to relapse and recurrence. 3) Biogenic Amine and Receptor Hypotheses - The primary hypothesis is the biogenic amine hypothesis which states that a deficit of NE, DA, or 5-HT at the synapse is the cause of depression. NE : Norepinephrine DA: Dopamine 5-HT: Serotonin Oxytocin Serotonin Endorphin Dopamine HAPPY BRAIN CHEMICALS 3) Biogenic Amine and Receptor Hypotheses - The primary hypothesis is the biogenic amine hypothesis which states that a deficit of NE, DA, or 5-HT at the synapse is the cause of depression. - The receptor hypothesis suggests that depression is related to abnormal functioning of neurotransmitter receptors. - In this hypothesis, chronic administration of anti- depressants alters receptor sensitivity causing desensitization or down regulation of ẞ-adrenergic and 5-HT receptors leading to therapeutic response. - Importantly, the time required for changes in receptor The primary hypothesis is the biogenic amine hypothesis which states that a deficit of NE, DA, or 5-HT at the synapse is the cause of depression. Support for this hypothesis is that existing antidepressants increase synaptic monoamine concentrations. OCTZ. MAT MAT erminal termirsal One argument against this hypothesis is that patients with depression do not always have decreased monoamine levels. Additionally, monoamine levels are altered within hours of initiating antidepressant therapy, but response is delayed by 2 to 4 weeks or more. astrocyte  Clinical Presentation & Diagnosis Patients typically present with a combination of emotional, physical, and cognitive symptoms Emotional: 1) Depressed mood most of the day almost every day, 2) Sadness Anhedonia Pessimism 3) Feeling of emptiness Irritability. Anxiety. Worthlessness Physical: 1. Disturbed sleep. Change in appetite/weight. 2. Decreased energy. Fatigue. 3. Bodily aches and pain. Cognitive: ‫ذهني‬ 1. Impaired concentration. 2. Indecisiveness. Poor memory Occasionally, severely depressed patients also will present with psychotic symptoms: Hallucinations* Delusions.  Anxious Depressed Woman Crying Anxious and nervous teenager overthinking and have mixed thoughts. Worried and overthinking woman with tangled mess in head Overthinking Anxious Man Teenager Diagnostic Criteria Anxious Woman with Mess in The diagnosis of a major depressive Head episode (MDE) requires the presence of five depressive symptoms for a Anxious Woman with tangled minimum of 2 weeks (nearly every mess in head day) that cause clinically significant effects. Anxious Person Wants to Be Left Alone The diagnosis of MDD is based on the presence of one or more MDEs during a person's lifetime Diagnostic Criteria One of the first 2 symptoms is a must in addition to other symptoms Depressed mood. Markedly diminished interest or pleasure in usual activities (anhedonia). Increase or decrease in appetite or weight. Increase or decrease in amount of sleep. Increase or decrease in psychomotor activity. Fatigue or loss of energy. Feelings of worthlessness or guilt. Diminished ability to think, concentrate, or make decisions. Recurrent thoughts of death, suicidal ideation, or suicide attempt. The symptoms are not due to the direct physiologic effects of a substance or medical condition. The symptoms must interfere with the patient's everyday ability to function. Diagnostic Criteria Five or more out of 9 symptoms (including 1or 2) in the same 2-week period 3 Change in weight or appetite 1 Depressed mode 4 Insomnia or hypersomnia 2 loss of interest or pleasure + 5 Psychomotor retardation or agitation 6 loss of energy or fatigue 7 worthlessness or guilt 8 impaired concentration 9 Thoughts of death or suicidal ideation or suicide attempts Patient Assessment Response: Improvement, either defined clinically or by rating scales (≥50% reduction in total score). Remission means that the depressed individual has been able to return to a normal level of social functioning. Recovery is a full remission that lasts for F days or longer. Relapse another episode of depression that happens fewer than 6 months after treatment of acute symptoms. Patient Assessment 1. Psychiatric history. 2. Psychometric instruments used to identify depression and assess its severity.????!!!!!!!!! 3. Physical examination and laboratory tests. 4. Medications and substance use. Patient Assessment 1.Psychiatric history A thorough history of symptoms is compared with the diagnostic criteria, and the diagnosis is made on the basis of collected data. 2. Psychometric instruments used to identify depression and assess its severity. A. Clinician rating scales B. Patient rating scales Patient Assessment A. Clinician rating scales The Hamilton Rating Scale for Depression (HAM-D): It is Often used to show efficacy in clinical trials for FDA approval of antidepressants. A common clinical trial enrollment score is greater than 18 (severe depression). A response is usually defined as at least a 50% reduction in the HAM-D score. "Remission" is a return to a normal state or a HAM-D of 7 or less. Useful way of determining a patient's level of depression before, during, and after treatment. On-line Hamilton Depression Scale 1. DEPRESSED MOOD (Sadness, hopeless, helpless, worthless) Absent These feelings are indicated only on questioning These feelings are spontaneously reported verbally Communicates feelings non-verbally i.e., through facial expression, posture, voice, and tendency to weep Patient reports VIRTUALLY ONLY these feelings in his spontaneous verbal and non-verbal communication 2. FEELINGS OF GUILT Absent Self reproach, feels he has let people down Ideas of guilt or rumination over past errors or sinful deed Present illness is a punishmnent. Delusions of guilt Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations 3. SUICIDE Absent Feels life is not worth living Wishes he were dead or any thoughts of possible death to self Suicide ideas or gesture Attempts at suicide (any serious attempt rates) De http://www.psy- world.com/online_hamd.htm http://www.psy-world.com/online_hamd.htm t rate e acitating ATIC SYMPTOMS- INTESTINAL appetite, heavy feeling in abdomen, tion) 0-Absent e GHT must be interpreted in terms of pa- tient's understanding and und.) s or doubtfull loss f Insight TEMS 1 TO 17: mal d Depression oderate Depression evere Depression Severe Depression MAT VADIATION Patient Assessment B. Patient rating scales Patient Health Questionnaire-9 (PHQ-9) It is based on the DSM-5 diagnostic criteria for major depression. It is easily administered and assessed. For this reason, it is often used in the primary care setting. Patients can be screened with an abbreviated version (the PHQ-2). If they test positive, the PHQ-9 is administered. The PHQ-9 can also be used to monitor treatment response Patient Assessment 3. Physical examination and laboratory tests These are necessary to rule out physical causes: Thyroid disorders, Vitamin deficiencies, Anemia, CVS diseases, Neurologic disorders, Chronic pain Cancer. 4. Medications and substance use They can induce depression as an adverse effect. Interferons, Alcohol, CNS depressants barbiturates), (benzodiazepines- ẞ-blockers (propranolol, sotalol), Cocaine and amphetamines withdrawal, Corticosteroids, Contraceptives Pharmacists should perform a drug and substance use review to identify possible causes. Suicide Risk Factors Depressive disorders are a major health care problem, contributing to 70% of suicide-related deaths RISK Previous suicide attempts Close family member who has committed suicide LOW HIGH Past psychiatric hospitalization Recent losses Social isolation Drug or alcohol abuse Exposure to violence in the home or the social environment Handguns in the home COURSE AND PROGNOSIS Symptoms of a major depressive episode usually develop gradually over days to weeks. Untreated, MDEs last 6 months or more. Approximately two-thirds of patients recover and return to normal mood, but one-third have only a partial remission. The number of previous episodes predicts the likelihood of developing subsequent episodes (>3 90% to have a 4th) MDD has a high mortality rate because approximately 15% of patients ultimately complete suicide. Treatment goals Resolution of depressive symptoms, Return to euthymia Prevention of relapse and recurrence of symptoms Prevention of suicide attempts Improving quality of life including normalization of functioning in areas such as work and relationships Minimization of adverse effects, and reduction of health care costs. Treatment Non- Pharmacological 1. Psychotherapy 2.Electroconvulsive therapy 3.Light therapy 4.Vagal nerve stimulation 5.Physical Exercise Pharmacological TCA MAOI SSRI SNRI Atypical De Treatment Non-Pharmacological 1. Psychotherapy Evidence supports efficacy of interpersonal and cognitive behavioral therapy in the treatment of MDD. Psychotherapy alone is AN INITIAL TREATMENT option for mild to moderate depression. It may be useful combined with pharmacotherapy for the treatment of severe depression. This combination can be more effective than either treatment alone in severe or recurrent MDD. THOUGHTS CBT EMOTIONS BEHAVIORS Treatment Non-Pharmacological 2. Electroconvulsive therapy (ECT) is a highly efficacious and safe treatment alternative for MDD (effective in severe depression). The response rate is 80% to 90%, and it exceeds 50% for patients who have failed pharmacotherapy. Indications: Severe suicidality, refusal to eat, pregnancy, or contraindication or refractory to pharmacotherapy, psychotic features, or if symptoms are severe or life threatening The usual cycle is two or three treatments per week. Six to 12 treatments are typically necessary with response occurring in 10 to 14 days. When ECT is discontinued, antidepressants are initiated to help maintain response. Side effects temporary confusion, retrograde and anterograde amnesia and heart rhythm problems in patients with pre-existing heart disease. Treatment Non-Pharmacological 3. Light therapy is an alternative treatment for depression associated with seasonal (e.g., winter) exacerbations. Side effects include eye strain, headache, insomnia. 4. Vagus nerve stimulation (VNS), which was approved by FDA in 2005, may be used depression. for treatment- resistant A pulse generator is surgically implanted under the skin of the left chest, and an electrical lead connects the generator to the left vagus nerve which sends signals to the brain. This therapy is used along with pharmacotherapy and ECT. Treatment Non-Pharmacological 5. Transcranial magnetic stimulation (TMS) is a noninvasive and well- tolerated procedure. 6. Physical exercise may reduce depressive symptoms, but well- controlled studies are needed to verify this. Electromagnetic cod Pulsed magnetic field Stimulated cortical region TMS Theory in Depression TMS coil placed over target brain region MagVenture Brain Activity of Target Brain Region Too low Too high Regions affected by depression Treatment Antidepressant therapy may lead to a more rapid response than psychotherapy, BUT when discontinued, there is a risk of relapse and adverse effects. All anti-depressants are considered equally efficacious Treatment Pharmacological Individual antidepressants, even those within the same class, have important pharmacologic differences Treatment Pharmacological First-line medications include SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), bupropion, and mirtazapine. In general, it takes 4–6 weeks to see the effect of antidepressants (given the correct drug, dose, and adherence) but it may take as long as 8 weeks to see a response. Remission may take up to 12 weeks. Remission is the goal of therapy. Remission is also defined as at least 3 weeks with no symptoms of depressed mood and anhedonia and no more than three remaining symptoms of depression. (Return to normal- HAM-D of 7 or less OR PHQ-9 less than 5).) Treatment Pharmacological Response to Antidepressants Failure: