County Of Riverside Noontime Health Seminar Depression September 2006

Depression
Introduction Up to 50% of primary care visits in an average clinical day have been estimated to involve some component of emotional distress that raises the possibility of a psychiatric condition [1] Depression is one of top five dx in primary care settings Depressed pts may present c weight loss or gain, sleep disturbances, loss of energy, or slowness of movement

Depression
CLASSIFICATION The three subgroups of depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) are: 1. Major depression 2. Dysthymia 3. Atypical depression or depression not otherwise specified (NOS)[2]. These need to be differentiated from grief and bereavement, which are normal responses to a loss. Seasonal affective disorder is not a separate mood disorder
it is classified as a specifier to major depression.

Depression
Major depression The DSM-IV criteria for major depression require that at least 5 of following 9 symptoms are present during the same period [2] 1. Depressed mood most of the day
particularly in the morning

2. Markedly diminished interest or pleasure in almost all activities nearly every day (anhedonia)
can be indicated by subjective account or observations by significant others

Depression
Major depression 3. Significant weight loss or gain 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or guilt 8. Impaired concentration, indecisiveness 9. Recurring thoughts of death or suicide

Depression
Major Depression One of the symptoms must be either depressed mood or loss of interest Symptoms should be present daily or for most of the day, or nearly daily for at least two weeks The symptoms must cause clinically significant distress or impairment in functioning
not due to the direct effects of substance (eg, drug abuse or medications) or a medical condition (eg, hypothyroidism) do not occur within 2 months of the loss of a loved one (unless associated c pathologic grief, see below)

A history of a prior manic episode in dditi t th it i t th

Depression
Minor depression Minor" depression, sometimes also called "atypical" depression,
but deserves particular mention because of frequency c which it occurs in the primary care setting

Similar to major depression, symptoms should be present daily or for most of the day, or nearly daily for at least two weeks Rather than having at least 5 symptoms, however, pts have only 2-4 depressive symptoms

Depression
Minor Depression Often characterized by hypersomnia & weight gain In contrast to the insomnia & weight loss assoc c major depression, Many pts c frequent complaints who have no medical explanation for their symptoms have minor depression [3] Furthermore, the term "minor" should not leave the impression that the illness is not important

Depression
Dysthymia more chronic, low intensity mood disorder By definition, symp must be present > 2 yrs consecutively It is charac by anhedonia, low self-esteem, & low energy It may have a more psychologic than biologic etiology
tends to respond to Rx & psychotherapy equally

Long-term psychotx is frequently able to bring about lasting change in dysthymic individualA

Depression
Grief & bereavement normal responses to the loss of close relationship Depression, suicide, anxiety, & complicated grief are most common adverse psychological sequelae of loss [6] Rates of depression during the first year after loss of a spouse are 15-35%
figures that are 4-9 times higher than rate of general population [7]

The risk of suicide also appears to be elevated among individuals who have lost a spouse
particularly in older men & in first year after a death [8]

Depression
Complicated or traumatic grief syndrome in which indivdoes not return to the level of function & well-being at which he or she lived before loss It involves persistence of reactions that are normal in immediate period after a loss
eg, difficulty accepting the death denial of the death absence of grief Searching preoccupation with thoughts of the deceased avoidance of reminders of the deceased auditory & visual hallucinations of the person who has died

Normal grief reactions are resolved in 94% of indiv by 13 months after a loss [7]

Depression
Seasonal affective disorder The criteria for adding the seasonal pattern specifier to dx of major depression include the following 1. Regular temporal relationship between onset of major depressive episodes & particular time of year
unrelated to obvious season-related psychosocial stressors

2. Full remissions (or a change from depression to mania or hypomania) also occur at a charac time of the year 3.Two major depressive episodes meeting the first two criteria in last 2 years & no nonseasonal episodes in the same period 4. Seasonal major depressive episodes substantially outnumber the nonseasonal episodes over individuals lifetime

Depression
EPIDEMIOLOGY Approximately 10-40% of pts in the primary care setting have significant depressive symptoms
but < 50% meet DSM-IV criteria for major depressive disorder [13]

The point prevalence for major depressive disorder in Western industrialized nations is 2.3-3.2% for men & 4.59.3% for women Lifetime risk for major depressive disorder is 7-12% for men & 20-25% for women A 2005 survey of over 43,000 US adults aged 18 and older found the 12 month prevalence of major depressive disorder to be 5.3% lifetime incidence 13.2% [14]

Epidemiology The following factors increased risk: female gender Native American descent middle-age, low income, divorced, separated, or widowed Risk was for Asian, Hispanic, & black ethnicity Depression was assoc c substance dependence, generalized anxiety disorder, & personality disorders Major depression occurs in 2-4% of indiv in the community, 5-10% of primary care pts 10 to 14% of medical inpts [15] Studies that have used formal criteria such as DSM-IV have found that the prevalence of "minor" depression is approximately twice that of major depression [16-18]

Depression

Depression
Epidemiology Depression in the elderly is assoc c significant health care costs [19] & functional decline [20] Lost productivity due to depression in US workers is estimated to cost employers an excess 31 billion dollars compared C workers without depression the majority of this loss is due to reduced performance while at work [21]

Depression
RISK FACTORS The primary risk factors for major depressive disorder include:
Female gender History of depressive illness in first degree relatives Prior episodes of major depression

The explanation for the female preponderance is not entirely clear

Contributing factors may include:
high incidence of postpartum depression social factors (eg, history of childhood abuse [22] low self-esteem) gender differences in metabolism of noradrenergic & serotonergic neurotransmitters [23,24]

Depression
Risk Factors Both animal & human studies suggest that early stressors (eg, childhood sexual abuse) cause long-term dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis similar to that seen in depressed pts [25] The HPA axis in women may be more susceptible to stress-induced dysregulation than in men
contributing to an vulnerability to depression in adult women more remote family history of depressive disorder lack of social supports significant stressful life events current alcohol and substance abuse

Other risk factors:

Depression
Risk Factors A systematic review found median current and lifetime prevalences of alcohol problems in pts with depression of 16 & 30% respectively [26]

The hypothalamic-pituitaryadrenal (HPA) axis in a normal person

The hypothalamicpituitary-adrenal (HPA) axis in depression

The serotonin pathways in depression

The noradrenaline pathways in depression

Depression
Biologic Basis of Depression Severe symp of major depression generally require some biologic intervention, either c antidepressants or ECT There is currently no biologic marker for depression, although the following may be seen in depressed individuals:
Early REM latency (dreaming as soon as falling asleep) Early morning awakening Poor appetite Weight loss Pseudodementia
cognitive performance that resolves c successful Rx of depressive symp

Depression
Biologic Basis of Depression Depression is assoc c physical changes in the brain A meta-analysis of MRI studies concluded that hippocampal volume, measured at a single point in time, is approx 10% in pts c unipolar depression
it is unclear whether this is an effect on the brain of repeated bouts of depression [30]

Conditions assoc c depression A number of medical conditions may present c depression, including: Stroke Diabetes Dementia

Depression
Conditions assoc c depression Cancer Hypothyroidism Chronic fatigue syndrome Fibromyalgia Systemic lupus erythematosus Coronary heart disease Corticosteroid use Anxiety and panic disorders Some Rx other than corticosteroids are also assoc c depression A causal link has not been established in all circumstances, although depression may resolve c tx of underlying medical conditions

Depression
Conditions assoc c depression In a study that looked at development of depression after a new dx of a serious chronic illness, the risk was highest after a dx of cancer (hazard ratio [HR] 3.6), chronic lung disease (HR 2.2), or heart disease (HR 1.5) [31] For most illnesses studied, the risk was greatest soon after dx & declined over time Hypothyroidism Several studies suggest that subclinical hypothyroidism is assoc c neuropsychiatric disease

Depression
Cardiovascular disease There is mounting evidence that depressive symptoms are assoc c cardiovascular risk However, it remains uncertain whether the symptoms are playing a causative role or whether they are primarily a marker or prodrome of an evolving event

Depression
Anxiety & Panic disorder Depression is common in pts c generalized anxiety disorder In addition, 1/3 to 1/2 of pts c panic disorder also meet DSMIV criteria for major depression at the initial presentation, while 60-90% have had one or more lifetime episodes of major depression [43-47] Other disorders Other disorders assoc c depression include:
Hypercalcemia Sjgren's syndrome Major depression may be assoc v seizure disorders in older adults [48] Pts c major depression have an risk for stroke & Parkinson's disease [49] Major depression may be assoc c bone loss [50]
Chronic pain
chronic pain complicates dx & tx of depression [51].

Depression
MAKING THE DIAGNOSIS Limited lab testing that may help rule out assoc disorders includes measurement of:
TSH Electrolytes Folate Vitamin B12 EKG