depression,suicide
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Depression, Suicide
Chapter 15 15.1 pages 527 to 562
Mood Disorders: Depression Mood is a pervasive and sustained
feeling that is experienced internally and that influences a person's behavior and perception the world.
Depression
Mood can be: normal,normal, elevated,elevated, or depressed.or depressed. Healthy persons experience a wide
range of moods and have an equally large repertoire of affective expressions; they feel in control of their moods and affects.
Mood Disorder: Depression Mood disorders are a group of clinical conditions
characterized by a loss of tha that sense of control and a subjective experience of great distress.of great distress.
Patients with elevated mood demonstrate expansiveness, flight of ideas, decreased sleep, and grandiose ideas.
Patients with depressed mood experience a loss of energy and interest, feelings of guilt,,difficulty in concentrating, loss of appetite,and thoughts of death or suicide.
Other signs and symptoms of mood of mooddisorders include change in activity level,,cognitive abilities, speech, and vegetative functions (e.g., sleep, appetite, sexualfunctions (e.g., sleep, appetite, sexualactivity, and other biological rhythms).
These disorders virtually always result in impaired interersonal, social, and occupational functioning
DSM-IV-TR Criteria for Major Depressive Episode Table 15.1-5-6
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of either loss of interest or pleasure.
DSM-IV-TR Criteria for Major Depressive Episode
Note: Do not include symptoms that are clearly
due to a general medical condition, or mood-incongruent delusions or hallucinations
Depressed mood most of the day, nearly every day,as indicated by either subjective report (e.g., feels sad or empty) or observation made by others).appears tearful)
DSM-IV-TR Criteria for Major Depressive Episode
markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day, (as indicated by either subjective account or observations by others)
significant weight loss when not dieting or weight gain (e.g., a change of more than 5% weight in a month), or decrease or increase in appetite nearly every day.
Note In children, consider failure to make
expectedIn children, consider failure to make expected weight gains.
DSM-IV-TR Criteria for Major Depressive Episode
insomnia or hypersomnia nearly every day
psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
DSM-IV-TR Criteria for Major Depressive Episode
fatigue or loss of energy nearly everyday feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly every (not merely self-reproach or guilt about being sick)
diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
recurrent thoughts of death (not just fear of recurrent fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan, or a suicide attempt or a specific plan for committing suicide.
Treatment
1. Guarantee patient safety2. Complete diagnostic evaluation of
the patient3. Treatment plan that addresses:
Immediate symptoms Patient’s prospective well-being
Pharmacotherapy
Once a diagnosis has been established a pharmacological treatment strategy can be formulated
Objective: Symptom remission not just reduction
Pharmacotherapy
Major depressive disorder Most antidepressants have a lag period of 10
days to approximately 4 weeks before a therapeutic response is noted
Increasing dose will not shorten this period, it will increase the incidence of adverse reactions
Pharmacotherapy
Antidepressants 3 main classes
Selective serotonin reuptake inhibitors (SSRIs) Tricyclic Antidepressants ( Tas) Mono amine oxidase Inhibitors (MAOIs)
All three classes work differently but all change brain chemistry to improve neurotransmission.
Pharmacotherapy
Therapeutic response Not all patients respond the same way to a
medication IF a patient fails to respond appropriately to
an antidepressant, he or she may respond positively to another antidepressant, including another drug of the same pharmacologic class
Similar positive responses to drug therapy can be obtained by augmenting the original drug with a drug of a different class.
SSRIs
SSRIs are the first choice in treating depression They are preferred over TAs and MAOIs
Less damaging to the heart Minimal anticholinergic effects Minimal hypotensive effects
Fluoxetin (Prozac) 1987, became the first SSRI approved by the FDA for use as antidepressant.
Currently sertraline (Zoloft) is one of the most widely used antidepressants in the United States.
Readings- Chapter 36.29 pg 1083-1090 See tables 36.29-1 and 36.29-2
SSRIs
Pharmacokinetics SSRIs have a broad range of serum half- lives
Fluoxetine has the longest half-life- 4 to 6 days; its active metabolite has a half-life of 7-9 days
SSRIs are well absorbed, peak effects range from 3 to 8 hours
All SSRIs are metabolized by the liver by cytochrome P450 (CYP) enzymes
Most interaction activities are related to inhibition of metabolism of coadministered medications.
Pharmacodynamics
SSRIs: Exert their therapeutic effects through 5HT
reuptake inhibition Higher dosages do not increase
antidepressant efficacy- may increase incidence of adverse effects
Citalopram and escitalopram are the most selective of the SSRIs
Other SSRIs also have actions on norepinephrine and dopamine receptors, causing reuptake inhibition.
Therapeutic Indication
In the US all SSRIs, except fluvoxamine have FDA approval for use in the treatment of depression.
Studies have found that antidepressants with serotonin-norepinephrine activity (MAOIs TCAs) produce higher rates of remission than SSRIs Venlafaxine & mirtazapine
In the past SSRIs have been link to a slight increase in suicide ideation. However the relation remains unclear
A noted increase in anxiety and agitation has been seen in some patients
Pregnancy and Postpartum Depression
Postpartum depression affects a small percentage of mothers
68 to 100 percent relapse in pregnant patients that discontinue therapy
Evidence suggests increased rates of special care nursery admission after delivery for children of mothers on SSRIs
SSRIs are secreted in breast milk; however [plasma] levels are usually very low in mothers that are breast feeding.
Depression in the Elderly SSRIs are safe and well tolerated
when used in the elderly and medically ill Little or no cardiotoxic effects Little or no anticholinergic effects Little or no antihistaminergic effects Little or no alpha-adrenergic adverse
effects
Depression in Children
Only fluoxetine has FDA approval for use as an antidepressant in this population
Reports indicate that SSRIs can increase suicidal and violent thoughts or actions in depressed children
Children treated with SSRIs require close monitoring
Precautions and Adverse Reactions Sexual dysfunction
Most common adverse effect of SSRIs GI
Very common, mediated largely through the effects on the serotonin 5HT receptors Nausea Diarrhea Anorexia Vomiting Flatulence Dyspepsia
Precautions and Adverse Reactions Headaches
18 to 20 percent of cases CNS adverse effects
Anxiety First few weeks
Insomnia & Sedation Improved sleeping resulting from
treatment of depression and anxiety Vivid dreams
Precautions and Adverse Reactions CNS adverse effects (cont.)
Emotional blunting Inability to express emotions
Yawning Seizures
0.1 to 0.2 percent Extrapyramidal Symptoms
Anticholinergic Effects Paroxetine
Mild anticholinergic effects
Hematologic Adverse effects Can cause functional impairment of platelet
aggregation Easy bruising, prolonged bleeding
Special monitoring suggested for patients on SSRIs and anticoagulants
Precautions and Adverse Reactions
Electrolyte and Glucose Disturbances SSRIs may decrease [glucose]
Careful monitoring for diabetic patients suggested
Endocrine and Allergic Reactions SSRIs can decrease prolactin levels
Mammoplasia and galactorrhea in both men and women
Various types of rashes- 4% of patients
Serotonin syndrome Concurrent administration of an SSRI with
MAOI, L-Tryptophan or lithium can raise plasma [serotonin] to toxic levels
Precautions and Adverse Reactions Sweating Experienced by some patients while on
SSRIs SSRI withdrawal
May exhibit withdrawal symptoms upon sudden discontinuation
Drug interactions see table 36.29-3
Suicide
Primary emergence for the mental health professional
Major public health problem Over 30,000 persons commit suicide
each year in the US More than 600,000 attempt suicide
Suicide: Risk Factors Gender
MORE COMMON IN MALE
Age 15-44
Race More common among white males
Religion Higher in Protestants and Jews than Roman Catholics
Marital Status Single, never married persons are twice more likely
to comit suicide than married persons. Divorce increases the likelihood of suicide Widows also have a higher rate
Suicide: Risk Factors cont. Social Status
The higher the person’s social status, the higher the incidence
A fall in social status also increases the risk of suicide
Occupations Both males and female physicians in the US have increase
rates of suicide
Climate No significant data indicates a correlation with climate and
suicide.
Physical Health The relation of physical health and illness to suicide is
significant
Mental Health Almost 95% of all persons who commit suicide have a
diagnosed mental illness.
Suicide: Risk Factors cont. Psychiatric Patients Psychiatric patients’ risk for suicide is 3 to 12 times that
of non psychiatric patients. Depressive disorders Schizophrenia Alcohol Dependence Other Substance dependence Personality Disorders
Suicide: Treatment Decision to hospitalize a patient with suicidal
ideation depends on: Severity of depression Severity of suicidal ideation Patient’s family’s coping ability Patient’s living situation Availability of social support Absence or presence of risk factors for suicide
Suicide: Pharmacotherapy Patients hospitalized can receive medication for
underlying diagnoses, leading to suicide ideations or attempts: Antidepressants Antipsychotics When patients present signs of both, medications
like risperidone (Risperdal) that have both antipsychotic and antidepressant effects are very useful.
Vigorous treatment should be initiated depending onunderlying disorder.
Supportive psychotherapy is also indicated. ECT may be necessary for severely depressed
patients