8:30-8:55 8:55-9:00 9:00-9:25 9:25-9:30 9:30-9:55 9:55-10:00 10:00-10:50 Afternoon

Genetics in the Mentally Ill Break Sleep Break Psychological Assessment Break Major Depression Blackboard Video Exercise #4

Lecture Schedule Changes

Old Schedule

New Schedule

Oct 25th

Oct 25th

Psychological Assessment, 9:30-9:55, Dr. Trede

Psychological Assessment, 9:30-9:55, Dr. Shu Final Exam Review, 8:309:10, Dr. Hughes Trauma Survivor Interview, 9:20-10:00 Death & Dying, 10:1011:00, Dr. Verma

November 1st

November 1st

Death & Dying, 8:30-9:10, Dr. Hankins Trauma Survivor Interview, 9:20-10:00 Final Exam Review, 10:1011:00, Dr. Hughes

8:30-8:55 8:55-9:00 9:00-9:25 9:25-9:30 9:30-9:55 9:55-10:00 10:00-10:50 Afternoon

Genetics in the Mentally Ill Break Sleep Break Psychological Assessment Break Major Depression Blackboard Video Exercise #4

ICM SAC: 9/20 & 10/25

Lonnie Kurlander lonniek@bu.edu

Michael Sherman mhsherm@bu.edu

Lauren Sigman lsigman@bu.edu

Ben Tannenbaum btann@bu.edu

Major Depression
Doug Hughes, MD Professor of Psychiatry Boston University

Major Depression

Lifetime prevalence of 5% to 10% Higher prevalence in certain groups like the medical ill Average age of onset is 40 Twice as common in females At greater risk of death from all causes No ethnic or socioeconomic differences Certain professions have significantly higher rates of depression and anxiety disorders

Empathic Concern

Empathic concern is how much one cares about others Those who score high in these areas are more likely to return incorrect change to a cashier when they believe no one is watching, give money to a homeless person, volunteer and not put it on their resume, help an animal or friend out, etc

Screening Questions for Diagnosing

Columbia University Study Journal of Pediatrics, July, 2006

Have you lost interest and pleasure in doing things (anhedonia)? Do you feel down or depressed, Children and males may report empty feelings).

DSM-IV: 5 or more of the symptoms & one or both of the top 2 symptoms
A. At least 5 symptoms for at least 2 weeks B. Symptoms cause significant distress and/or impairment C. Symptoms not due to drugs, alcohol, or medical illness. D. If bereavement, usually symptoms must persist for at least 2 months
SYMPTOMS Depressed mood * Anhedonia * Weight loss, >5% Sleep problems Psychomotor < or > Chronic fatigue Worthlessness Poor concentration Suicide thoughts * Must have one or both

S uicide recurrent thoughts with or without a plan I nterest markedly diminished interest or pleasure, others may note it G uilt excessive or inappropriate, feeling of worthlessness, may be delusional E nergy fatigue or loss of energy nearly every day C oncentrate diminished ability to think/decide or as observed by others A ppetite 5% body weight loss in a month, or decreased or increase in appetite
nearly every day. Note: In children, consider failure to make expected weight gains.

P sychomotor agitation or retardation every day, observable by others S leep, insomnia or early morning wakening nearly every night, Hypersomnia
present in atypical depression or bipolar depression

Depression and Suicide

15 % of people with major depression eventually commit suicide Mood disorders account for 50-70 % of all suicides Suicide is more common in men than in women Suicide is more common in the elderly but may be increasing in adolescents Risk of suicide is highest in untreated depression and in the early treatment phase with antidepressants If a patient mentions suicide, follow up with an open-ended question to get more information

Assisted Suicide

Not always clear what is a suicide v an accident Physicians may asked by their dying or suffering patients to assist in their death. This is called euthanasia and is illegal in all States except Oregon, Washington, & Montana Death is defined as irreversible cessation of all functions of the entire brain, including the brainstem, often certified by a flat electroencephalogram (EEG)

Diagnostic Challenges

Normal v Abnormal/Pathological Grief

Normal Minor weight loss <5lb Minor sleep disturbances Some guilt feelings Illusions Attempt to return to work Cries, expresses sadness Severe symptoms <2 m Moderate symptoms < 1 year Usually do not treat

Abnormal/Pathologic Significant weight loss Significant sleep issues Intense guilt Hallucinations, delusions Resumes few activities Consider suicide Severe symptoms >2m Nearly always treat

Masked Depression

Possibly 50% of depressed patients are unaware or deny symptoms of depression, are said to have masked depression Patients often visit their primary care physicians and complain of vague physical symptoms. These symptoms can be misdiagnosed as hypochondrias or anxiety

Atypical Depression

A variant of major depression where patients gain weight rather than lose, and are more likely to show excessive somnolence

Medical Differential

Drug abuse, alcohol and illicit drugs, particularly freebase cocaine (shortest time to onset and shortest duration of action) Cancer, particularly pancreatic and other gastrointestinal tumors Viral illness such as pneumonia, HIV/AIDS (most STDs are usually not associated with depression) Endocrine abnormalities, such as hypothyroidism

Patients with Cancer

Many illnesses, particularly cancer, results in loss of energy, decrease appetite, weight loss, trouble sleeping all of which are also symptoms of depression Also hospitalized patients because of the stressful environment have trouble sleeping, may not like the food, not able to access their hobbies, etc all of which make diagnosing depression more difficult Concentration and excessive guilt may be the best indicators of depression

Treatment

Major Depression Treatment

Antidepressants; the SSRIs as first line agents (paxil, prosaz, zoloft), effectiveness is not clear Be careful with SSRIs with the new FDA, Black Box warning about greater suicide risk for adolescents, probably the case for adults. Tricylics are just as effective but have more anticholinergic side effect; tachycardia, conduction disturbances. Avoid in cardiac patients Lithium is both a good augmenting agent for antidepressant medications Lithium may also be used by itself initially in treating the depressed and suicidal patient as it decrease impulsivity (found to decrease suicide rates, one of only two medication that do this)

Cycle of Despair
Alcohol Abuse Alcohol Dependence Drug Abuse

Depression

Substance Abuse

Major Depression Atypical Depression Dsthymia

Violence

Suicide Homicide Child Abuse

Video

This video interview of a patient has many symptoms see if you can make a diagnosis After the video we will have Turning Point questions so dont talk during video with your neighbor

11 minutes

DSM-IV: 5 or more of the symptoms & one or both of the top 2 symptoms
A. At least 5 symptoms for at least 2 weeks B. Symptoms cause significant distress and/or impairment C. Symptoms not due to drugs, alcohol, or medical illness. D. If bereavement, usually symptoms must persist for at least 2 months
SYMPTOMS Depressed mood * Anhedonia * Weight loss, >5% Sleep problems Psychomotor < or > Chronic fatigue Worthlessness Poor concentration Suicide thoughts * Must have one or both