Depression

Snapshot

• A 27-year-old female presents with insomnia of recent onset stating that she has been waking up at 3 am every day.  Upon further questioning the patient admits to feeling excessive fatigue lately and trouble focusing in school and at work.  She also admits that she is no longer interested in high speed cup stacking (sport stacking) her previous life passion. The patient states that she has had a depressed mood lately and that she has thought about suicide at times.

Major Depressive Episode

• Diagnostic criterion
  • at least 5 of the following 9 symptoms for 2 weeks
    • “SIG E CAPS”  
      • Sleep disturbance
      • loss of Interest (anhedonia)
      • Guilt or feelings of worthlessness
      • loss of Energy
      • loss of Concentration
      • Appetite/weight changes
      • Psychomotor retardation or agitation
      • Suicidal ideations
      • depressed mood
    • must include depressed mood and anhedonia (inability to enjoy activities)
    • can also present with subjective pain that is not related to anatomical structures 
• Epidemiology
  • lifetime prevalence
    • 5-12% male
    • 10-25% female
  • increased risk with low socioeconomic status
• Biochemical changes 
  • ↓ NE, 5-HT, and dopamine 
• Related disorders
  • major depressive disorder, recurrent
    • >/= 2 major depressive episodes
    • 2 months symptom-free
  • dysthymia 
    • milder form of depression lasting at least 2 years 
    • similar symptoms to major depressive disorder but patient can function
  • seasonal affective disorder
    • associated with winter season
    • improves in response to full-spectrum light exposure
  • atypical depression
    • see below
    • most common subtype of depression
  • bipolar disorder
    • according to the DSM-V manic symptoms can exist leading to a diagnosis with “mixed features”
    • mixed features increases the likelihood that patient’s condition exists on a bipolar spectrum
  • major depressive disorder, with psychotic features 
• symptoms of major depressive disorder in addition to simultaneous psychotic symptoms (most commonly auditory hallucinations), which do not occur outside of mood episodes

Sleep Patterns of Depressed Patients

• Depressed patients show characteristic changes in sleep patterns
  • ↓ slow-wave sleep
  • ↓ REM latency
  • ↑ REM early in sleep cycle
  • ↑ total REM sleep
  • repeated nighttime awakenings
  • early-morning awakening
• improved symptoms with sleep deprivation

Atypical Depression

• Characterized by
  • hypersomnia
  • overeating
  • leaden paralysis (feeling of heaviness in limbs)
  • mood reactivity
    • i.e., can feel happy when happy events occur, not persistently sad
• Associated with
  • weight gain
  • sensitivity to rejection
• Treatment
  • MAO inhibitors
  • SSRIs
• combining these drugs increases the risk for serotonin syndrome

Electroconvulsive Therapy (ECT)

• Treatment option for major depressive disorder refractory to other treatment and for pregnant women
• Produces a painless seizure in an anesthetized patient
• Major adverse effects
  • disorientation
  • anterograde/retrograde amnesia
• can be minimized when ECT is performed unilaterally

Grief

• Normal grief – normally less than 6 months with a cause but normal grief can last up to 1 to 2 years 
  • shock
  • denial
  • guilt
  • somatic symptoms
  • may experience hallucinations of deceased person
  • can precipitate a major depressive episode in a vulnerable individual (history of depression, family history)
• Pathologic grief – persistent and causes functional impairment 
  • excessively intense
  • prolonged
  • absent or inhibited grief
  • delusions
  • hallucinations
• Considered major depression when
  • suicidal features appear
  • greater than 6 months
• SIGE CAPS symptoms

Postpartum Depression

• Postpartum “blues” 
  • considered “normal” 
    • 50-85% incidence
  • depressed affect, tearfulness, fatigue
  • follow up in 2 weeks if does not resolve
  • mother unlikely to hurt baby
• Postpartum depression 
  • 10-15% incidence
  • depressed affect, anxiety, poor concentration
  • lasts 2 weeks to 2 months, then it is considered major depression
  • treat with antidepressants and psychotherapy
  • be watchful – mother may hurt infant though less likely
• Postpartum psychosis
  • 0.1-0.2% incidence
  • delusions, confusion, unusual behavior, and homicidal/suicidal ideation
  • lasts days to 4-6 weeks
  • treat with antipsychotics, antidepressants, and hospitalization if necessary
  • ensure the baby is protected – highest likelihood mother will hurt baby