− Australian prevalence of depression is 1 in 7

− 3rd highest burden of disease in Australia

− MDD (Major depressive Disorder) associated with high mortality rate (suicide)

 

ArTIOLOGY & rPIDrMIOLOGY

− Depression affects 1 in 7 (17%) women vs. 1 in 10 (10%) men

− Genetic factors (2-4 times more likely to develop depression)

− Multifactorial

− Neurochemical (serotonin in the brain)  − rnvironment

 

RISK FACTORS

− Family history

− Personality (e.g. having a low self esteem)

− Serious medical condition

− Situational (e.g. adverse life events)

− Gender

− Alcohol & Other drug use (AOD)

− Absence of protective factors (e.g. support network, financial situation, education)

 

 

Suicide-

− Suicide is responsible for over 900,00 deaths globally per year

− Approx. 90% of people who commit suicide meet criteria for one DSM disorder  − 35-44 year old have highest suicide rates  − Methods:

  • Hanging, strangulation, suffocation (54.5%)
  • Poisoning by drugs (14.5%)
  • Poisoning by other methods (8.5%)
  • Firearms (6.8%)
  • Drowning, jumping, other (15.8%)

 

 

DSM 5 Classification- MDD (Major depressive Disorder) 

  • 5 or more of the following symptoms for same 2 week period (must include at least 1 & 2)
    • Depressed mood (dysphoria)
    • Markedly diminished interest or pleasure in all or most activities most of the day, nearly every day (anhedonia)
    • Significant weight loss when not dieting, weight gain, decrease/increase in appetite
    • Insomnia or hypersomnia nearly every day
    • Observable psychomotor agitation or retardation nearly every day
    • Fatigue or loss of energy nearly every day (anergia)
    • Feelings of worthlessness or excessive or inappropriate guilt nearly every day
    • Diminished ability to think or concentrate, or indecisiveness nearly every day
    • Recurrent thoughts of death, suicidal ideation without a specific plan or attempt

Development & course 

  • Likelihood of onset increases with puberty (peaking in 20s)
  • Chronicity of symptoms increases the likelihood of underlying personality, anxiety, substance use disorders   Higher rate of relapse

 

Serotonin Syndrome 

  • Relatively rare condition but when it does occur it can be fatal (mortality 2-12%)
  • Care with titration of AD’s when changing
  • Serotonergic agents such as all other AD’s, pethidine, tramadol, LSD, busiprone, amphetamines, cocaine, ecstasy, lithium & St Johns wort can all cause this syndrome

 

Antidepressant Abrupt/Withdrawal Discontinuation Syndrome 

  • May cause withdrawal symptoms

−  Flu-like symptoms

− Insomnia

− Nausea

− Imbalance

− Sensory disturbances

− Hyper arousal (agitation/anxiety)

  • Usually short duration & mild
  • Need for tapering and titration

 

 

 

 

 

Switching Medications (Anti depressants) 

  • Strategies to change medication:

− Direct switch

− Taper & then immediate switch

 

 

rlectroconvulsive Therapy (rCT)

− Taper & then switch after a washout period

− Cross titration

 

− Used to treat Major Depressive Disorder (MDD) and Bipolar Disorder and chronic Schizophrenia  − 2-3 sessions/week, for a total of 6-12 sessions

− Very effective- 90% of patients using it experience improvement

− Uses general anaesthetic (GA)

− Induced seizure 70-150 volts via electrodes (bilaterally 1 on each side; unilaterally, both on 1 side)  − Seizures last 30-60 seconds  − Side effects:

  • Transient short term memory loss
  • Headache o Confusion o Nausea
  • Muscles aches

 

 

Trans Magnetic Stimulation (TMS)

− Less invasive then rCT

− Option for patients who cannot tolerate other methods (AD’s, psychotherapeutic interventions)  − 40min/session 5 days/week

− Timed variable magnetic field, administered via a coil placed over the scalp, to stimulate brain activity

 

 

Bipolar Affective Disorder I & II (BPAD)

− Diagnosis can take 10-20 years

− Manic episodes are more common as 1st presentation in mean

− Depressive episodes are more common as 1st presentation in women

− High incidence of non-adherence to Tx

− High incidence of suicide

− More than 90% of BPAD sufferers will experience recurrence

 

 AETIOLOGY & EPIDEMIOLOGY OF BPAD

  • Australian lifetime prevalence for BPAD I is up to 1% (no gender variance)
  • Australian lifetime prevalence for BPAD II is up to 5% (higher rate in women)
  • rmergence is usually mid-to-late adolescence
  • More common in high income countries

 

 

BPADI- Manic Episode 

  • Always has mania
  • Abnormally elevated, irritable, elevated and expansive mood lasting 1 week & present most of the day
  • Highly aroused- difficult to interrupt
  • Three or more of the following (4 if mood is only irritable):
    1. Inflated self esteem or grandiosity
    2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
    3. More talkative than usual or pressure to keep talking
    4. Flight of ideas or subjective experience that thoughts are racing
    5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
    6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposelessness non-goal-directed activity)
    7. rxcessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

 

 

BPAD I&II- Hypomanic Episode 

  • “mini mania” no mania episode/no psychotic features
  • Distinct period of abnormally elevated, expansive or irritable mood lasting 4 consecutive days
  • No hospitalisation
  • The episode is not severe enough to cause impairment
  • Three or more of the following (4 if mood is only irritable)
    1. Inflated self esteem or grandiosity
    2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
    3. More talkative than usual or pressure to keep talking
    4. Flight of ideas or subjective experience that thoughts are racing
    5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
    6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
    7. rxcessive involvement in activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

 

 

 

 

Treatment of BPAD’s 

  • Antipsychotic medication
  • Mood stabilising medication
  • rCT
  • Counselling
  • Anxiolytics
  • Antidepressants (with care)

MOOD STABILISERS 

 MEDICATION  DOSAGE  SIDE EFFECTS  BENEFITS & DISADVANTAGES 

Lithium carbonate  1800 (a)  Nausea, vomiting, diarrhoea, 75% will experience S/r 900-1200mg (m)  weight gain, tremor, fatigue,  polydipsia, polyuria   rfficacy in reducing suicide vs.

other mood symptoms

Sodium Valporate   400-1500mg   Weight gain, acne, hair loss, Rapid onset mediation that is

GI upset  well tolerated

Carbamazepine  200-1600mg   Drowsiness, dizziness, Less sedating then other

(uncommon)   headache, fatigue & nausea  mood symptoms

Lamotrigine  50-200mg  Dizziness, drowsiness, rfficacy in managing bipolar

headache, tremor, blurred depression & BPADII

vision, confusion

Observe for rash (life threatening)

 

 

BPAD Relapse

 

Postpartum ‘Blues’

− Common in men & women , 30 days after bitch

− Transient

− Mood liability, irritability, tearfulness

− Feeling of sadness

 

DEPRESSION- PERIPARTUM ONSET

o Consider impact of unplanned pregnancies, dysfunctional relationships etc. contributing  o Prolonged, more serious version of baby blues  o May present with over-concern with infant  o Can present with psychotic features  o 50% of episodes actually begin prior to delivery  o Symptoms occur within 12 weeks of birth & include: depressed more, severe anxiety, panic attacks

 

ASSESSMENT

  • RISK- self, others, vulnerability, spending
  • MSr
  • PHYSICAL ASSrSSMrNT- nutrition, sleep, elimination

PSYCHOrDUCATION- understanding of illness, mx