Professional Documents
Culture Documents
Benefit-Finding: (% endorsing)
• Relationships: “If you can’t be normal, be spectacular!!!”
– My friends and family have become more helpful (77), I am
closer to my family (70), I am closer to my significant other
(51), I keep in better touch with my family (44)
• Interpersonal Skills:
– I have learned to be more compassionate (67), to be more
respectful of others (58), express more feelings (55), QuickTime™ and a
communicate better (48), be a better friend (48), TIFF (Uncompressed) decompressor
are needed to see this picture.
• Perspective:
– I appreciate the importance of being independent (83), I
appreciate life more (74), I am more introspective (72),
more conscientious and self-disciplined (60), more
motivated to succeed (59), more spiritual (45), more
independent in many ways (38), less inhibited (33)
Anatomy of Despair:
There is no despair so absolute as that which Demoralization vs Depression
comes with the first moments of our first
great sorrow,
when we have not yet known what it is to
have suffered and be healed,
to have despaired and have recovered hope.
George Eliot (1819-1880)
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Demoralization (Frank & Frank, 1993) Who Cares About Caregivers (CG)?
• Demoralization = state of helplessness, hopelessness,
confusion, subjective incompetence, isolation and • Poorly studied but critically important aspect of all chronic illnesses.
diminished self-esteem.
• There are both positive and negative aspects to being a CG.
– Results from failure to adapt when environmental stress
• Well-being of CG is crucial to well-being of care-recipient (CR).
overwhelms an individual’s coping capacity.
• CG report increased frequency of loss, loneliness and isolation.
– An individual’s coping capacity is influenced by constitutional
variables and resources. • Decreased wellness of CG because of neglect of their own health.
• Subjective thoughts, feelings, beliefs of demoralized • MS CR variables associated with increased CG burden:
individuals: – Unstable course, increased physical disability, depression, and pain.
– Failed to meet expectations: their own and/or others’ expectations. • CG & CR are in it together:
– Overmastered: – In sickness and in health.
• Feeling of being unable to cope with some pressing problem. – My body/My spouse’s body/My family
• Simultaneous feelings of being powerless to change situation or
extricate themselves from predicament.
– Isolated:
• Feeling of being unique and therefore not understood.
MDD
Are you getting enough oxygen?
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
What is Depression???
If You’ve Never Had It (Tx), Forget What You Know
• Mood thermostat in brain gets stuck
– Mostly fixed, unresponsive low mood.
– Accompanied by physical Sx: e.g. concentration, sleep, energy,
appetite.
– Brain alterations (e.g. REM, hippocampus).
• Drugs exploit the fact that the brain regulates our mood.
– Cocaine
• ALS: Tuesday’s With Morrie
• Under-appreciation of the role of biology…
– It’s NOT all in your mind!
– MS/TM Sx Onset -> Must convince physician.
– Depression Sx Onset -> Must convince yourself.
2
Forget what you “know” about depression: Medical Causes of Depression:
Common myths in and out of Medicine
• Neurologic disorders: CVA (25-50%), subdural hematoma, epilepsy (45-
55%), brain tumors (30%), Parkinson's disease (30-50%), Huntington's
• Depression is a state of mind, weakness or character flaw disease(40%), syphilis, Alzheimer's disease (15-50%)
– Genetics • Autoimmune disorders: DM (30%), SLE (25-44%), RA (30-50%), Multiple
Sclerosis (37-62%), Transverse Myelitis
– REM latency
• Drug induced: reserpine (15%), interferon-alpha (10-57%), β-blockers,
– DST corticosteroids, estrogens, benzodiazepines, barbiturates, ranitidine, Ca2+-
– Medical causes of depression (MS, TM, NMO, etc) channel blockers
• Substance induced (25%): EtOH, sedative-hypnotic, cocaine &
psychostimulant withdrawal
• Metabolic: hyper/hypothyroidism, Cushing's syndrome, hypercalcemia,
hyponatremia, diabetes mellitus
• Nutritional: vitamin B12 deficiency
• Infections: HIV, HCV, mononucleosis, influenza
• Cancer (20-45%): especially pancreatic CA (40-50%)
(DHHS, 2002)
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Major Depression vs Sadness: DSM IV Inventory: SIGEMCAPS
• Major depression is a syndrome. • Sleep ( ⇓ / ⇑ )
• Interest (or pleasure)
• It is not just severe sadness. • Guilt (or worthlessness)
• Sadness is to major depression what cough is to • Energy (fatigue)
pneumonia. • Mood
– Cough can be an indicator of pneumonia. • Concentration
– Not every cough is the result of pneumonia. • Appetite ( ⇓ / ⇑ or weight loss or gain)
– Sometimes pneumonia presents without a cough. • Psychomotor retardation (or agitation)
– Consider the company the cough keeps. • Suicidal ideation (or thoughts of death)
• Productive sputum, tachypnea, fever, consolidation • ≥5/9 Sx for ≥2 weeks
Jean-Martin Charcot(1825–1893):
Disseminated Sclerosis
Burden of Depression in MS Patients
• Grief, vexation, and adverse changes in (Patten & Metz, Psychother Psychosom, 1997, 66:286-92)
social circumstance were related to the
onset of MS. • Lifetime Prevalence:
• 1868, The Lectures on the Diseases of the – 37-62% MS
Nervous System to medical students at La
– 17% General Population (NCS)
Salpetriere in Paris
• Current Prevalence:
• Charcot, Lecture VII, 1868.
– Mlle. V. was a 31-year-old woman with 8 yr – 14-27% MS
history of DS. – 5% General Population (NCS)
– Experienced periods of serious depression
accompanied by paranoia that caused her to
suspect Charcot of trying to poison her.
– As a result, she ceased eating and had to be
fed by a stomach pump to keep her alive.
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Depression and MS Impact of Depression in MS
• Depression is common in patients with MS and
is associated with considerable morbidity and • Quality of Life
mortality. • Function
• The available evidence suggests depression in –Primary relationship
MS is caused by the effects of inflammatory
insults to the brain. –Work
– No correlation with physical disability. –Treatment Adherence
– No genetic loading. • Cognition
– Periods of immune activation correlate with • Fatigue
increased depression and suicides.
• Longevity
Introduction to Transverse Myelitis (TM): Depression Scores in TM, MS and the General Population
TM Defined
90
84
• Transverse: 80
crosswise direction; 62
60
– often opposed to longitudinal. T
49 51
• Myelitis: 50 Euthymic
Mild-Mod
0 - 59
60-69
– An inflammation or infection of 40 39
35
Severe 70-81
All Depression 60-81
the spinal cord. 30
31
20
14 16 16
10 8
2
0
Gen Pop MS TM
5
Quartile distribution of test scores in ATM and MS patients Correlation Between Neurological
Disability and Depression Scores
100%
90%
80%
70%
Sexual Fxn
MS
60%
50% Series4
Series3
Bladder Disab
40% Series2
30%
Series1
Motor Disab
20%
10%
Sensory Disab
0%
MMSE Trails Trails Rey- FAS
A B recall
Sensory Disab
100% r=0.307, p=0.004*
90%
70
Depression
80% Motor Disab
70% r=0.020, p=0.901
60% 60
TM 50%
Series4
Bladder Disab
40% Series3
Series2
Series1 50 r=0.060, p=0.731
30%
20% Sexual Fxn
10% 40 r=0.026, p=0.875
0%
MMSE Trails Trails Rey- FAS
1 2 3 4 5
A B recall Disability
Potential Effects of Treating Depression on MS: Treatment of Depression in MS is Associated with Decreased
• Chronic stress has been linked to increased risk for MS IFN-gamma Production by Autoaggressive T Cells
exacerbations as well as accrual of disability. (Mohr, et al) (Mohr et al, 2001, Arch Neurol, UCSF)
• A prospective, longitudinal investigation involving serial • Patients with depression had biological evidence of worse
imaging using MRI with gadolinium demonstrated that MS disease severity.
stressful life events (especially family conflict and work • Treatment of depression in MS patients (with either
related stress) predicted the development of new and active medication or psychotherapy) correlated with
brain lesions. improvement in their autoimmune disease status.
• A meta-analysis of studies examining the effects of stress • Suggests that treatment of depression may be an
on MS exacerbation found a significantly elevated risk of important component in the management of MS:
exacerbation associated with stressful life events in 13 of – “Treatment of depression may provide a novel disease-
the 14 investigations. modifying therapeutic strategy as well as a
• The degree that stress increased the risk of MS symptomatic treatment for patients with MS.”
exacerbations in this meta-analysis was on average 60% • Stress has been linked to increased risk for MS
greater than the degree that IFN-beta treatment has been exacerbations as well as accrual of disability. (Mohr, et al)
shown to decrease the risk of MS exacerbations.
6
Forget what you “know” about depression:
Common myths in and out of Medicine
• 5. Depression is not treatable…
– I can think of no other illness that has the same burden of morbidity
and mortality of MDD that can be put into 100% symptomatic
remission with proper recognition and treatment.
– USAF experience: Suicide Prevention Program 1996-1998.
Unintentional
Injury (48%)
Suicide (23%)
Disease (21%)
Homicide (5%)
Other (3%)
MMWR
“Of course your daddy loves you.
He’s on Prozac--he loves everybody.”
“I have had to face many challenges in my life. I have had to endure numerous
physical and emotional hardships. But my positive attitude and my sense of hope for
today and the future have never been diminished. My life is good, because I will have it
no other way. My life is beautiful, because I choose to see life this way. We cannot
control all of what happens with our bodies, and we cannot control what goes on in the
Acknowledgements:
world around us. But we do control how we think about and feel about ourselves and
our families and the world we live in. And it is all good; life is very, very good.” • Douglas Kerr & Chitra Krishnan
• CUFSF & TMA & TM/MS Patients/Families
• Ben Greenberg & Peter Calabresi
• JHTMC & JHMSC
• Michele Pucak & Edward Hammond
• David Edwin & Karen Swartz
• Glenn Treisman & Peter Rabins
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“No pill can help me deal with the
problem of not wanting to take pills; likewise, no
amount of psychotherapy alone can prevent my
manias and depressions. I need both. It is an odd
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
30
20
10
0
-IV Steroid+IV Steroid
(Nature Med, Feb 2005)
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Immune Activation
IL-6
Stress
Cortisol
Hippocampal Neurogenesis Decreased Division
Antidepressant
Growth of New Neurons Hippocampal Shrinkage
BDNF
Mood Regulation Depression
“Of course your daddy loves you.
Learning & Memory Cognitive Impairment He’s on Prozac--he loves everybody.”
RR SRE
3
QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Linear (RR SRE)
0
0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 0.16
Clearance
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Forget what you “know” about depression:
Five common myths in and out of Medicine
• 4. There are two simple myths that are used inappropriately to
dismiss the diagnosis of depression.
– Patients are not depressed, they are stressed.
• Stress is not protective against depression, especially medical stress.
• DSM does not make allowances for stress.
– OK they’re depressed, but you’d be depressed too if you had their
illness.
• Depression is not the inevitable consequence of stress.
• ALS & Tuesdays with Morrie.
• MS and disability.
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Effects of Treatment of Depression on MS Treating MS Depression
• Treatment related-reductions in depression in MS patients are
associated with reductions in T-cell production of IFN-gamma • MS depression is usually unremitting and tends to get worse
(IFN-y) (Mohr). without treatment.
• IFN-y is the main proinflammatory cytokine produced by activated • Only DBPC Trial was Desipramine x 5 wks.
T cells that has been shown to precede and cause exacerbations and – Desipramine improved depression more than placebo.
new brain lesions in MS patients. – 50% of patients on deisipramine had to limit dose because of side-
effects.
• T cells isolated from depressed MS patients were found to be primed
to produce twice the levels of IFN-y than T cells from non-depressed • Open label trials:
controls. – Fluvoxamine: 80% response rate.
• Treatment with sertraline or psychotherapy reduced depression that – Setraline: 90% response rate.
was paralleled by declines in T-cell IFN-y production, which • Psychotherapy:
returned to control levels. – CBT > Insight Oriented
• Treating depression might prove to be an important disease • Exercise.
modifying component in MS treatment.
Studying Depression: Depression Has Been Known Since The Time Of The Greeks:
(HS Akiskal, Comp Text Psych, 6th ed & Galen, Diseases of the Black Bile, 165 CE)
In Search of Homogeneity
• Hippocrates (460-357 BC) first described "melancholia"
• SIGEMCAPS • MSGEC ("black bile") as a state of "aversion to food, despondency,
• MSIGE • MSGECA sleeplessness, irritability, [and] restlessness."
• MSGECAP
• MSIGEC • He believed the illness arose from the substrate of the somber
• MSGECAPS
• MSIGECA melancholic temperament, which, under the influence of the
• MSIEC
• MSIGECAP
• MSIECA
planet Saturn, made the spleen secrete black bile, which
• MIGEC
• MSIECAP
ultimately darkened the mood through its influence on the brain.
• MIGECA
• MSIECAPS… • Furthermore, Hippocrates “declared that the bile inflicts damage
• MIGECAP
• MIGECAPS
to the brain as an instrument,” thereby impairing its “function as
• SIGEM ICAPS
an organ” and affecting the intellect.
11
DSM IV Inventory: SIGEMCAPS • Epidemiology of Major Depressive Disorder
• Sleep ( ⇓ / ⇑ ) (MDD):
• Interest (or pleasure) – Current (30d) prevalence: 5%
• Guilt (or worthlessness) – Lifetime prevalence: 17% (M 12%, F 21%)
• Energy (fatigue) – Peak age of onset 20-40 years old.
• Mood
• Concentration
• Appetite ( ⇓ / ⇑ or weight loss or gain)
• Psychomotor retardation (or agitation)
• Suicidal ideation (or thoughts of death)
• ≥5/9 Sx for ≥2 weeks
Treat Demoralization with Remoralization Who Cares for Caregivers? (Peter Rabins: 36 hr Day)
• Problem-focused coping skills to instill sense of mastery. • Care-Provider’s who care about patients care about CG.
– e.g.: rest periods to combat fatigue, shop non-peak hrs, etc. • CG & CR must remember they are in this together.
– Cumulative small victories can re-instill confidence. – Coping strategies must therefore be complementary.
– Combats helplessness, diminished self-esteem, frustration. – There’s not just one way to adapt to life under altered circumstances.
• Individual and group support and education. • Problem-focused coping skills.
– e.g.: this conference, friends, counselors, care-providers. – What can and can’t be changed.
– Combats hopelessness and isolation. – Continually increased distress by either CR or CG means something new
• Cognitive reframing must be tried. Avoid entrenchment in a failed solution.
– e.g.: “reality checks”, untreatable memory disorder becomes • Information is crucial.
organizational problem. – CG must be informed about TM.
– Combats subjective sense of incompetence & confusion. • What you don’t know can scare you…a lot!!!
• Education can provide tools to help problem solve.
• Occasional reminder that its OK to be merely human.
– Peer education is often invaluable. You’re not the first to need advice.
– e.g.: nonjudgmental setting where feelings can be expressed
• As a CG, ask “how am I doing?” (physically, emotionally, etc).
– Taking care of CG’s needs doesn’t conflict with CR needs.
– CG is no good to CR if she/he is burnt out. Know how to get help.
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Depression and Cognition Depression and Fatigue
• Some degree of cognitive impairment occurs in 50% of MS
patients: • Depression strongly associated with impact of fatigue on lives
– Memory recall, information processing speed, executive of MS patients (vs. occurrence).
function, working memory • Association of depression with fatigue is type specific (Siegert &
Abernathy, 2005, JNNP):
• Cognitive deficits also found in moderate-severe MDD.
– Mental fatigue, r=0.54, p<0.0001
– Performance in depressed MS patients may be normal for – Physical fatigue, r=0.31, p<0.01
routine tasks but impaired on tasks involving effortful • Disabling fatigue = often or almost always interferes with
attention. activities (Chwastiak, et al, 2005, JPR):
– Depression in MS associated with impairment of complex – MS subjects with depression 6x more likely to report disabling
speeded attention, planning and working memory. fatigue.
– Impairment can wax and wane with type of task and mood. – Presence of disabling fatigue had sensitivity & specificity of 70%
for predicting significant levels of depression.
• Conclusions:
– Both MS and depression have overlapping cognitive deficits.
– Combination of two is additive in resulting impairment.
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