DEPRESSIVE DISORDERS

Types of Disorders
• Major Depressive Disorder
• Medically-Induced Depressive Disorder
• Drug-Induced Depressive Disorder
• Disruptive Mood Dysregulation Disorder
• Premenstrual Dysphoric Disorder
• Persistent Depressive Disorder

MAJOR DEPRESSIVE DISORDER

Definition
A persistently depressed mood lasting for a minimum of 2 weeks.

S/S (5+ symptoms)

Physical
• Periodic crying
• Anergia
• Suicidal ideation and/or action
• Trouble concentrating
• Vegetative symptoms: those that impair necessary functions of life
o Changes in appetite & weight
o Insomnia or hypersomnia

Emotional/Behavioral
• Depressed mood most of the day, every day
• Low self-esteem
• Feelings of guilt
• Feelings of hopelessness/helplessness
MEDICALLY-INDUCED DEPRESSIVE DISORDER

Definition
A form of depression caused by the presence of another chronic, painful, disabling, and/or
life-limiting disease.
• During the assessment of these patients, you must first rule out the possibility that
a drug used to treat the etiologic condition is not causing the depression

Development

CLASS EXAMPLES
Neurologic Epilepsy, Parkinson’s, MS, AZD, Huntington’s, TBI, CVA
Infectious Neurosyphilis, HIV/AIDs
Cardiac Ischemic heart disease, cardiac failure, cardiomyopathies
Endocrine Hypothyroidism, DM, vitamin deficiencies, parathyroid disorders
Inflammatory Collagen-vascular diseases, IBS, chronic liver disorders
Neoplastic CNS tumors, paraneoplastic syndrome

DRUG-INDUCED DEPRESSIVE DISORDER

Definition
Depression that is the result of prolonged use, or withdrawal from, certain drugs.
• The depressive symptoms exceed the physiologic response of use/withdrawal

S/S
Physical
• Depression that abates in response to full discontinuation or the end of drug
withdrawal
o Symptoms of depression typically appear within 1 month of use
o Symptoms usually remit within days/weeks of discontinuation

Development

CLASS EXAMPLES
CNS Depressants alcohol, barbiturates, benzos, clonidine
CNS Drugs amantodine, bromocriptine, L-dopa, phenothiazines, phenytoin
Psychostimulants amphetamines
Systemic Drugs corticosteroids, digoxin, diltiazem, enalapril, ethionamide, isotretinoin,
mefloquine, M-dopa, metoclopramide, quinolones, reserpine, statins,
thiazides, vincristine
DISRUPTIVE MOOD DYSREGULATION DISORDER

Definition
A childhood disorder characterized by situationally-inappropriate outbursts more than
normal for their developmental level.

S/S
Physical
• Outbursts of rage towards peers, family, and/or self

Emotional/Behavioral
• Severe irritability & anger
• Verbal/behavioral outbursts 3+ times per week
• Inability to maintain emotional control in certain settings
o Diagnostically, lack of control should be seen in 2 or more of the traditional
environments (home, school, with peers)

Interventions
Medical
• Antidepressants – cases resembling presentation of MDD → treats depressive
symptoms & irritability
• 2nd generation antipsychotics (Risperdal/Abilify) → treats irritability
• ADHD medications (Adderall/Concerta) → reduces hyperactivity

Therapeutic
• Cognitive behavioral therapy
o Teaching consequences of outbursts
• Parent training
o Teaching consistency to reduce aggression/irritability
o Rewarding appropriate behavior, not placating inappropriate behavior
• Computer-based training
o Improve understanding of facial expressions
PREMENSTRUAL DYSPHORIC DISORDER

Definition
A sequela to PMS, with more serious depressive symptoms that affects functioning.

S/S
Physical
• Anergia
• Overeating
• Hypersomnia or insomnia
• Breast tenderness
• General complaints of aches/bloating
• Weight gain

Emotional/Behavioral
• Mood swings
• Irritability
• Depression
• Anxiety
• Feeling overwhelmed
• Difficulty concentrating

Interventions
Medical
• Combination contraceptives (Yaz) → regulate hormone levels
• SSRIs (Prozac, Zoloft, Paxil) → reduce depressive symptoms
• Diuretics → reduce bloating & weight gain
Alternative
• Regular aerobic exercise
• Increasing dietary complex carbs during the menstrual period
• Increasing hours/day of sleep
• CAT: acupuncture, light therapy, & relaxation therapy
PERSISTENT DEPRESSIVE DISORDER

Definition
Depressive symptoms that occur most of the time, for a period of 2+ years.

S/S
Physical
• Chronic fatigue with anergia
• Vegetative symptoms: those that impair necessary functions of life
o Changes in appetite & weight
o Insomnia or hypersomnia
o Significant impairment in sociality & academic/occupational success

Emotional/Behavioral
• Poor self-esteem
• Poor concentration & memory
• Trouble making decisions
• Feelings of hopelessness/despair

CENTRAL INTERVENTIONS FOR DEPRESSIVE DISORDERS

Assessment/Diagnosis
• Some patients may have “mood congruent” auditory hallucinations
o They will encourage the patient to act on/accept their feelings, and are a
troubling feature in patients with suicidal thoughts that may precede an
attempt at suicide
• All patients expressing depression should be assessed for suicide potential & risk
• The PHQ 9 tool is a questionnaire used to gauge feelings within the past two weeks

Thought Processes
• Intrusive negative thoughts
• Delusions & dissociative symptoms
• Slowed decision-making

Phases of Recover from Major Depression

Acute Phase (6-12 weeks)
• Focused on reducing symptoms & restoring functionality
• May need hospitalization in additional to psychotherapy & psychopharmacology

Continuation Phase (4-9 months)

• Focused on the prevention of relapse
• Providers will use therapy, medication, & education to lower relapse risk

Maintenance Phase (1+ years)

• Focused on preventing further episodes of depression
• May include phasing out medication (if applicable)
Medical Interventions

Reuptake Inhibitors
• Selective Serotonin Reuptake Inhibitors (SSRIs)
o Blocks reuptake of serotonin
o Take 3-4 weeks to take effect
o ↑ risk of suicide in patients <24 years old
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
o Blocks reuptake of serotonin & norepinephrine
o Cymbalta shouldn’t be given to PTs with hepatic/renal problems, or a history
of alcohol abuse
• Dopamine-Norepinephrine Reuptake inhibitors
o Blocks reuptake of dopamine & norepinephrine
o Increases the risk for seizures
• Serotonin Syndrome is a complication of antidepressant therapy from abnormal
elevations of available serotonin
o S/S: shock, abdominal pain, fever, & diarrhea

Tricyclics (TCAs)
• Block the reuptake of norepinephrine & serotonin
• Used less frequently now, due to the high level of adverse effects, and their
reputation of poor patient tolerance leading to poor adherence
• Can cause fatal overdoses, and will cause heart failure if used with alcohol

MAO Inhibitors (MAOIs)

• Prevent the breakdown of norepinephrine, dopamine, & serotonin
• Interact with many other medications/foods
• Must be discontinued before surgery
• MAOI toxicity is a complication of eating foods containing tyramine while using
these drugs
o Induces a life-threatening hypertensive crisis
o Foods to avoid: chocolate, beer/wine, aged cheese, fermented foods

Contraindications to Antidepressant Use

• Acute schizophrenia → elevated dopamine levels from reuptake inhibition in
SNRIs/DNRIs/MAOIs may trigger schizophrenia S/S
• Mixed manic-depressive disorder → treated with mood stabilizers
• Suicidal tendencies → certain drugs (SSRIs) may trigger a suicidal episode in
certain patients
• Severe renal, hepatic, or cardiovascular disease → these are difficult drugs to
tolerate, and impaired metabolic function ↑ risk for A/E
• Narrow-angle glaucoma → the anticholinergic properties of some drugs (TCAs) can
exacerbate vision loss
• Seizure disorders → drugs that retain dopamine (Buproprion) can induce seizures
Therapeutic Interventions
• Psychotherapy
o Talk therapy
o Cognitive behavioral therapy
• Hospitalization
o This is more common in MDD than PDD
o Indicated if the patient is a suicide risk, a threat to others around them,
and/or if their depressive disorder has impaired their self-care abilities
• Stimulation therapies
o Transcranial magnetic stimulation → to the skull
o Vagus nerve stimulation → to the nerve path in the neck
o Used less frequently because of high expense, and the invasive nature of the
treatment
• Electroconvulsive Therapy (ECT)
o Used in cases where antidepressant therapy is not effective
o Requires 6-15 treatments for a marked benefit
o Most commonly used in the elderly, because medications are less effective in
treating their depressive symptoms
o Patients receiving ECT are first given a short-acting anesthetic & a paralytic
o A/E: short-term memory loss, headache, risk of death

Alternative Interventions
• Yoga, or other forms of aerobic exercise
• St. John’s Wort
o An herbal supplement that may reduce anxiety & depressive symptoms
o Shouldn’t be combined with long-term antidepressant or anxiolytic use
(especially Cymbalta/MAOIs)