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31 Cards in this Set

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DSM -IV Criteria for depression
5 or more symptoms - 2 week period - change from previous functioning
at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure--anhedonia

(3) significant weight change (+/- 5% loss in one month,
(4) sleep change
(5) psychomotor agitation or retardation
(6) fatigue or loss of energy
(7) poor concentration or indecisiveness
(8) feelings of worthlessness or excessive and inappropriate guilt
(9) recurrent thoughts of death

[do not include symptoms due to a general medical condition, or mood-incongruent delusions or hallucinations]

Not bi-polar

clinically significant impairment of functioning

not due to drug abuse or medical condition (e.g., hypothyroidism)

Not Bereavement
(after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation)
Major Depressive Disorder
Epidemiology
Women 2ce as likely

Usually later in life, mid thirties

Monozygotic twin studies have clearly shown a genetic component.
Point prevalence of depression in males & females?
males: 2-4%; Females: 5-9%
Depression: Age of onset?
mid-late 30s
Depression: Social class?



Family history?
Poverty = more depression



17%
Depression: race?
lower in aisans
Depression & bipolar: Family history
17% with major depression have family history

2-3% with bipolar disorder have family history
concordance in twins
40% monozygous
11% in dizygous
Psychological Theories of Depression: Psychoanalytic
Theorist: Freud
Primary disturbance: Fixation of development at the oral stage
Precipitant: Real, threatened or perceived loss
Key Features: Disruption leads to fall in self esteem & depression; depression as “anger turned inward”
Psychological Theories of Depression: Behavioral **
Theorist: Lewihson
Primary disturbance: Lack of social skills
Precipitant: decrease in response contingent positive reinforcement (RCPR)
Key Features:
decrease in RCPR leads to dysphoria; clinical depression is a result of the secondary gain
Psychological Theories of Depression: Cognitive
Theorist: Beck
Primary disturbance: Dysfunctional attitudes
Precipitant: Enviornmental stressor
Key Features:
Activation of depressogenic schema trigger all other symptoms of depression
Psychological Theories of Depression: Learned Helplessness
Theorist: Seligman
Primary disturbance: Dysfunctional attributional style
Precipitant: Negative events
Key Features:
Internal, stable, and global interpretation of the cause of negative events to the belief that future actions will have no effect on outcome
Theory of Attachment
Bowlby described the phenomenon of attachment bonds, a genetically based affectional tie between the mother and the infant. These bonds lead to formation of object constancy, disruptions in the development of which may predispose to marked dependency needs and depression.
Psychosocial Theories for Depression:
Pre-morbid personality types :oral, dependent, avoidant, obsessive, compulsive and histrionic most prone to depression.

History of developmental trauma (abuse or neglect) at least doubles the lifetime risk of depression.
Depression: Course and Outcome
15% relapse w/in 12 weeks of recovery
33% within 1 year &
75% within 5 years.

Prognosis worsens with increased severity of symptoms at onset--less acute onset, and acute episode superimposed upon a chronic depression = higher risk (double depression)
Depression: intervals between as people age
Interval between episodes becomes shorter as individuals age.
Subtype-Melancholic
5 of the following:
-pervasive anhedonia
-mood unreactive to pleasurable stimuli
-mood worse in am
-early morning awakening
-psychomotor retardation or agitation
-significant anorexia or weight loss
-no premorbid personality disturbance
-previous history of major depressive episode with complete recovery and good response to antidepressant or somatic treatments.
Pharmacotherapy: Antidepressants-First Line
What are they?
What is the response?
SSRIs, SNRIs, bupropion

50% of patients with depression respond to a first trial of an antidepressant. 70-90 % respond to a series of trials.
When Medication is Preferred for Depression
History of prior positive response
Severe symptomatology
Significant sleep or appetite disturbances or agitation
Anticipation of need for maintenance therapy
Patient preference
Lack of available alternative treatment modalities
Psychotherapy: Cognitive behavioral therapy (CBT)
identifies automatic negative thoughts that affect an individual’s mood
Psychotherapy: Interpersonal Therapy
addresses difficulties with relationships and/or transitions in life. It has been shown to be efficacious for patients suffering from depression.
Psychotherapy: Psychoanalytic
Insight oriented
Psychotherapy: Family Therapy
can address difficulties at home that may be exacerbating depressive symptoms
ECT
Electroconvulsive Therapy is usually reserved for refractory cases, but are very effective and can have minimal side effects. Side effects include temporary memory impairment that can be very concerning to patients.
Dysthymic Disorder
"mini-depression prolonged"
Chronic nonpsychotic and subsyndromal depression that lasts at least 2 years
It requires 3 of the 9 symptoms used for major depression. This was formerly referred to as depressive neurosis or characterological depression.
Dysthymic Disorder: epidemiology
It is common among unmarried, young adults, and lower socio-economic status. Prevalence is about 3%; but is 25 - 30% in psychiatric outpatient populations
Dysthymic Disorder: Course and Outcome
-Starts before the age of 25 in 50% of people
-25% percent never attain complete recovery
-20% go on to have a major depression
-15% have a hypomanic episode and 5% have frank mania resulting in bipolar I.
Dysthymia commonly leads to marital difficulties, school failure, substance abuse and unemployment.
Dysthymic Disorder: Comorbitities
co-occurs commonly with personality disorders. This comorbidity often makes it more difficult to treat. Other comorbidities are anxiety disorders and substance use.
percent of depressed patients that experience manic episode later in life

Factors predicting mania are:
20 - 30% patients will experience a manic episode later in life.

Factors predicting mania: pharmacological induction of , history of post partum depression, early onset (< 25 yrs.), & symptoms of hypomania and psychomotor retardation
Percent of depressed that commit suicide w/o adequate treatment
15% of patients will commit suicide without adequate treatment;
risk factors for suicide include:
risk factors for suicide include:
severe chronic depression, h/o previous attempts, family h/o suicide,
age,
race,
marital status,
sex,
concurrent substance abuse and presence of medical illness.