Course Outline
Chapter 1. Depressive Illnesses
- Depression Is An Illness
- Recognizing Serious Depression
- Clinical Evaluation
- Suicide
- Causes of Depression
- Genetic Factors
- Biochemical Factors
- Environment and Other Factors
- Treatments
- Drug Therapy
- Psychosocial Therapy
- Electroconvulsive Therapy
- Treatment Choice
- Mild Episodes
- Moderate Depressions
- Severe Depressions
- Hospitalisation
- Chronic Depressions
- Childhood Depressions
- Adolescent Depressions
- Depression Among The Aged
- Helping The Depressed Persons
- Where To Receive Treatment
Chapter 2. Depression In Women
- A Picture of Dipression
- What is Depression?
- Types of Depressive Illness
- Symptoms of Depression and Mania
- Causes of Depression
- The Many Dimensions Of Depression In Women
- Women At Risk
- Developmental Roles
- Reproductive Life Cycle
- Specific Cultural Considerations
- Depression Is A Treatable Illness
- Helping Resources
- Helping Yourself
- Helping The Depressed Person
- References
Chapter 3. Depression Is A Treatable Illness: A Patient’s Guide
- People Who Treat Depression
- Symptoms of Depression
- Another Form of Depression
- Preparing For Your First Visit
- Severe? Moderate? Mild?
- Treating Depression
- Types of Treatment
- How Treatment Works
- Choosing a Treatment
- About Hospitalization
- If You Have Concerns About Your Treatment. . .
- Antidepressant Medicines
- My Questions About Medicine
- Feeling Better
- Psychotherapy
- Types of Psychotherapy
- Choosing Psychotherapy
- Electroconvulsive Therapy
- Light Therapy
- Taking Care of Yourself
- Talking to Others About Depression
- Your Family and Friends
- Your Children
- Weekly Activity Record
- Panel Members
- Abstract
- Executive Summary
- Overview
Chapter 1. Guideline Development
- Background
- Definition of Depression
- Literature Reviews and Guideline Developement
- Interpretation of Scientific Literature
Chapter 2. Guideline: Overview of Mood Disorders
- Major Depressive Disorder
- Clinical Features and Course
- Epidemiology
- Costs of Untreated Major Depressive Disorder
- Subgroups of Major Depressive Disorder
- Dysthymic Disorder
- Clinical Features and Course
- Epidemiology
- Costs of Untreated Dysthymic Disorder
- Depression Not Otherwise Specified
- Clinical Features and Course
- Epidemiology
- Costs of Untreated DNOS
- Bipolar Disorders
- Clinical Features and Course
- Epidemiology
- Subtypes of Bipolar Disorder
- Cyclothymic Disorder
- Mood Disorder in Special Age Populations
- Children and Adolescents
- Geriatric Patients
Chapter 3. Guideline: Depression Co-Occurring with Other Psychiatric Conditions
- Alcohol/Drug Abuse or Dependency
- Anxiety Disorders
- Eating Disorders
- Obsessive-Compulsive Disorders
- Somatization Disorder
- Personality Disorders
- Grief and Adjustment Reactions
Chapter 4. Guideline: Depression Co-Occurring with Other General Medical Disorders
- Stroke
- Dementia
- Diabetes
- Coronery Artery Disease
- Cancer
- Chronic Fatigue Syndrome
- Fibromyalgia
Chapter 5. Guideline: Depression Associated with Medications
- Antihypertensives
- Hormones
- Histamine-2 Receptor Blockers
- Anticovulsants
- Levodopa
- Antibiotics
- Antiarrhythmics
Chapter 6. Guideline: Detection of Depression
- Clinical Clues
- Screening Instruments
- Patient Self-Report Questionnaires
- Clinician-Completed Rating Scales
- Differential Diagnosis of Depression
- Laboratory Tests
- Psychological Tests
- Ongoing Clinical Reassessment
- References
- Acronyms
- Abstract
- Executive Summary
- Overview
Chapter 1. Guideline Development and Methodology
- Rationale for Guideline Developement-The Cost of Depression
- Methodological Background
- Specific Methodological Strategies
- Review of the Literature
- Meta-Analysis
Chapter 2. Guideline: Aims of Treatment
- Benefits and Harms of Treatment
- Medications
- Psychotherapy
- Combination of Medication and Psychotherapy
- Electroconvulsive Therapy
- Clinical Management
- Improving Adherence to Treatment
- Measuring Outcome
- Declaring a Treatment Response or Failure
- Switchiing Versus Augmenting Treatments
Chapter 3. Guideline: Strategic Planning for Acute Phase Treatment
- Objectives of Acute Phase Treatment
- Indiccations for Acute Phase Treatment
- Treatment Selection
- Selection of Medication
- Selection of Psychotherapy Alone
- Selection of Combined Treatment
- Select of ECT
- Treatment Refusal
Chapter 4. Guideline: Acute Phase Management with Medication
- Indications for Acute Phase Medication
- Evidence of Efficacy
- Antidepressant Medication Selection
- Frequency of Visits
- Medication Dosage Adustments
- Antidepressant Drug Blood Levels
- Failure to Respond
- Continue Medication
- Switch Medication
- Augment Medication
- Add Psychotherapy
- Obtain a Consultation
Chapter 5. Guideline: Acute Phase Management with Psychotherapy
- Obejectives and Indications
- Evidence for Efficacy
- Cognitive Therapy
- Behavioral Therapy
- Interpersonal Psychotherapy
- Martial Therapy
- Brief Dynamic Psychotherapy
- Factors Affecting Response to Psychotherapy
- Selection of a Psychotherapy
- Frequency of Visits
- Failure to Respond
Chapter 6. Guideline: Acute Phase Management with Medication and Psychotherapy
- Objectives and Indications
- Evidence of Efficacy
- Selection of a Combined Treatment
- Frequency of Visits
- Dosage Adjustments
- Failure to Respond
Chapter 7. Guideline: Acute Phase Management with ECT
Chapter 8. Guideline: Special Situations
- The Suicidal Patient
- Geriatric Depression
- Seasonal Depression
- Depression and Other Nonpsychiatric Medical Disorders
- Depression and Other Psychiatric Disorders
Chapter 9. Guideline: Continuation and Maintenance Treatment Options
- Objectives and Indications for Continuation Treatment
- Objectives and Indications for Maintenance Treatment
- Continuation/Maintenance Phase Management with Medication
- Evidence of Efficacy
- Frequency of Visits
- Medication Dosage Adjustments and Antidepressant
- Symptom Breakthrough
- Discontinuation of Medication
- Continuation/Maintenance Phase Management with Psychotherapy
- Cognitive Therapy
- Behavioral Therapy
- Interpersonal Psychotherapy
- Marital Therapy
- Brief Dynamic Psychotherapy
- Factors Affecting Decisions about Continuation/Maintenance
- Frequency of Visits
- Symptom Breakthrough
- Continuation/Maintenance Phase Management with the Combination of Medication and Psychotherapy
- Evidence of Efficacy
- Discontinuation of Treatment
- A Second Opinion or Referral
- Primary Care Practitioners
- Patients and Families
- Consultations with Mental Health Care Professionals
- References
- Acronyms
- Glossary
- Contributors
Purpose of Activity
Good reliable medical info can be hard to find sometimes but there are many great places online for good health information. Mental health is also the same way, but there are also good places to find great info on things such as anxiety disorders and major depression.
About Authors
Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis. Clinical Practice Guideline, Number 5. Rockville, MD. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 93-0550. April 1993.
Depression Guideline Panel. Depression in Primary Care: Volume 2. Treatment of Major Depression. Clinical Practice Guideline, Number 5. Rockville, MD. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 93-0551. April 1993
Learning Objectives
Upon completion of the course you’ll be able to:
- Depressive illnesses affect the lives of million of Americans and cost billion of dollars.
- In the United States, nearly 10 million people experience a depressive illness during any 6-month period.
- Persistent sad, anxious or “empty” feelings
- Decreased energy, fatigue, being “slowed down”
- Loss of interest or pleasure in usual activities, including sex
- Sleep disturbances (insomnia, early-morning waking, or oversleeping)
- Appetite and weight changes (either loss or gain)
- Feelings of hopelessness, pessimism
- Feelings of guilt, worthlessness, helplessness
- Thoughts of death or suicide, attempts
- Difficulty in concentrating, remembering, making decisions
- Chronic aches or persistent bodily symptoms that are not caused by physical disease.
- Decreased need for sleep
- Increased risk-taking
- Increased energy
- Unrealistic beliefs in their own abilities
- Increased talking and physical, social and sexual activity
- Feelings of mood elevation or irritability
- Aggressive response to frustration.
- physical examination which includes a neurological examination and lab tests.
- a medical and psychiatric history
- a mental status examination
- high incidence of depressive illness could be inherited
- mood disorders could be a function of a biochemical disturbance and could be treated with drugs
- sleep patterns of both unipolar and bipolar depressed patients are different from those in persons who do not have a mood disorder.
- Personal losses, financial problems, physical illness midlife crises, sex role expectations, and psychosocial phenomena, such as personality, upbringing, and negative thinking style have been cited as contributors to depressive illness.
- Social conditioning also has been cited as contributing to a higher incidence of depression among women.
- Three categories of drugs are most often prescribe: tricyclics, monoamine oxidase inhibitors (MAOIs) and lithium.
- There are “talking” therapies during which problems are discussed and resolved through the emotional support, insights and understanding gained from the verbal give-and-take. Other therapies concentrate on behaviors: patients are taught to be more effective in obtaining rewards and satisfaction through their own actions.
- Although ECT has received unfavorable publicity, it continues to be the most effective treatment for major endogenous or delusional depression.
- Childhood depression may be recognized or misdiagnosed when depressive symptoms are mixed with other type of behavior, such as hyperactivity, delinquency, school problems, or psychosomatic complaints.
- Manic-depressive disorder in adolescents is often manifested by episodes of impulsivity, irritability, and loss of control alternating with periods of withdrawal.
- The wide range of estimates of occurrence of depression among older populations–from 10 percent to 65 percent–attests to the difficulties of diagnosing depression in an elderly person. Symptoms of depression are often misdiagnosed as senility (organic brain syndrome) or mistaken for the everyday problems of the aged.
- Women are disproportionately affected by depression, experiencing it at roughly twice the rate of men.
- Research continues to explore how the illness affects women and to identify new areas that hold promise of deepening our understandi
- Varied factors unique to women’s lives are suspected to contribute to depression–developmental, reproductive, hormonal, genetic, and other biological factors; abuse and oppression; interpersonal factors; and certain psychological and personality characteristic
- Who gets depressed?
- What is depression?
- How will I know if I am depressed?
- What should I do if I have these symptoms?
- How will I treatment help me?
- What type of treatment will I get
- General health care provider
- physician
- physician assistant
- nurse practitioner
- Mental health specialists
- psychiatrist
- psychologist
- social worker
- psychiatric nurse specialist
- antidepressant medicine
- psychotherapy
- antidepressant medicine combined with psychotherapy.
- How well each of these treatments works depends on the type of depression, how severe the depression is, how long you have been depressed, how you as an individual may react to treatment, and other factors.
- Major depressive disorder consists of one or more moods disorders episodes of major depression with
- or without full recovery between episodes.
- Dysthymic disorder features a low-grade, more persistent depressed mood and associated symptoms
- for at least 2 years, during which a major depressive episode has not occurred. Over extended followup, many patients with this disorder develop episodes of major depression.
- Depression not otherwise specified (DNOS) is a residual category for patients with symptoms and signs of depression that do not meet the formal diagnostic criteria for either major depressive or dysthymic disorder.
- Bipolar I disorder features at least one manic episode along with (nearly always) major depressive episodes.
- Bipolar disorder not otherwise specified is a residual category that includes bipolar II disorder, a condition characterized by recurrent episodes of major depression along with hypomanic (but not full-blown manic) episodes, as well as other forms that do not meet formal criteria for bipolar I or cyclothymic disorder.
- Cyclothymic disorder is characterized by numerous periods of mild depressive symptoms insufficient in duration or severity to meet the criteria for major depressive episodes interspersed with hypomanic episodes; it lasts at least 2 years by definition. Patients with this condition are rarely free of mood symptoms.
- Risk factors for major depressive disorder include female gender, a history of depressive illness in first-degree relatives, and prior episodes of major de
- Prior episodes of depression.
- Family history of depressive disorder.
- Prior suicide attempts.
- Female gender.
- Age of onset under 40.
- Postpartum period.
- Medical comorbidity.
- Lack of social support.
- Stressful life events.
- Current substance abuse.
- Conduct a clinical interview to determine whether the nine specific signs/symptoms of major depressive disorder according to DSM-III-R are present.
- Interview the patient to investigate the possibility of concurrent substance or alcohol abuse and current use
- of medications that may cause depressive symptomatology.
- Conduct a medical review of systems to detect the existence of medical disorders that may biologically cause or be commonly associated with depressive symptoms.
- Interview the patient further to detect the presence of another concurrent nonmood psychiatric condition that may be associated with and be responsible for the depressive symptoms.
- Exclude alternative causes (1 through 4, above) for depressive symptoms or syndromes to diagnose a primary mood disorder
- Major depressive disorder may begin at any age, although it usually begins in the mid-20s and 30s. Symptoms develop over days to weeks. Some people have only a single episode, with a full return to premorbid functioning. However, more than 50 percent of those who initially suffer a single major depressive episode eventually develop another.
- The point prevalence for major depressive disorder in the Western Industrialized nations is 2.3 to 3.2 percent for men and 4.5 to 9.3 percent for women. The lifetime risk for major depressive disorder is 7 to 12 percent for men and 20 to 25 percent for women.
- Patients with major depressive disorder have substantial amounts of physical and psychological disability, as well as occupational difficulties.
- Melancholic
- Atypical
- Postpartum psychosis/depression
- Seasonal
- Postpartum psychosis/depression.
- Psychotic features refer to the presence of delusions or hallucinations. They occur in 15 percent of patient with major depressive disorders.
- Psychomotor retardation or agitation
- Loss of interest or pleasure
- Lack of reactivity to usually pleasant stimuli
- Worse depression in the morning
- Early morning awakening
- overeating
- oversleeping
- weight gain
- a mood that still responds to events (reactive mood).
- extreme sensitivity to interpersonal rejection
- a feeling of heaviness in the arms and legs.
Anxious features include:
- marked anxiety
- difficulty in falling asleep
- phobic symptoms
- symptoms of sympathetic arousal
- episodes are recurrent (at least two episodes by some criteria, three by other criteria).
- there has been a regular temporal relationship between the onset of the major depressive episodes and a particular period of the year (such as regular onset of depression in fall and offset in spring).
- seasonal episodes substantially outnumber nonseasonal episodes.
- The essential feature of dysthymic disorder is a chronic of mood disturbance (sadness in adults; sadness and, possibly, irritability in children and adolescents) present most of the time for at least 2 consecutive years (1 year for children and adolescents).
- Psychoactive substances, such as cocaine and amphetamines; head trauma; certain neurologic diseases; endocrinopathies; and some other disorders can produce secondary manic and hypomanic episodes similar to those seen in primary bipolar disorder. In addition, in some patients with a family history of bipolar disorder, antidepressant medications can precipitate a manic or hypomanic episode.
- Cyclothymic disorder features numerous, alternating hypomanic and mild depressive periods, lasting daysto weeks and nearly continuous. There are few truly symptoms-free periods. The symptoms fluctuate, but never reach the severity/duration, criteria of major depressive or manic episodes. The course is chronic, often lasting yea
- Depressive symptoms or syndromes often accompany anxiety, panic, or phobic disorders. Furthermore, anxiety disorder may be the forerunner of and part of the longitudinal course of a mood disorder. The presence of both anxiety/panic and a major depressive disorder results in a more severe disorder with greater impairment than does either disorder alone. When the patient complains of anxiety symptoms, major depressive symptoms should be elicited.
- The practitioner is advised to ask about anorexia nervosa and bulimia nervosa in young women who present with any mood disorder, especially those with amenorrhea. If present, the eating disorder is the principal target of treatment.
- For those depressed patients whose disorder has some obsessive features, the mood disorder is the initial focus of treatment. If full-blown OCD is present with depressive symptoms or manic-depressive disorder, the OCD is usually the initial objective of treatment. Evidence from OCD medication treatment trials suggests that, if the OCD is treated successfully, the depressive symptoms usually abate.
- Somatization is defined as the presentation of somatic symptoms by patients with underlying psychiatric illness or psychosocial distress. These somatic symptoms have no, or insufficient, underlying organic cause.
- Personality disorders are not uncommon among mood-disordered patients. The presence of a personality disorder does not exclude diagnosis of a mood disorder, if present. When both a major depressive and personality disorder are present, more frequent and longer major depressive episodes, as well as poorer interepisode recovery (if untreated), may be anticipated.
- The general medical disorder biological causes depression for example, hypothyroidism may cause depressive symptoms.
- The general medical disorder triggers the onset of the depression in those who are genetically vulnerable to depressive disorders; for example, Cushing’s disease may precipitate a major depressive episode.
- The general medical disorder psychologically causes the depression; for example, a patient with cancer may become clinically depressed as a psychological reaction to the prognosis, pain, and incapacity. The general medical disorder and the mood disorder are not causally related.
- social isolation
- recent losses
- a tendency to pessimism
- socioeconomic pressures
- a history of mood disorder
- alcohol or substance abuse
- previous suicide attempt(s)
- poorly controlled pain
- Cardiovascular drugs
- Hormones
- Psychotropics
- Anticancer Agents
- Anti-inflammatory Anti-infective agents
- assess the patient for the nine specific sings/symptoms of major depressive disorder
- investigate the possibility of concurrent substance or alcohol abuse
- detect the existence of medical disorders
- detect the presence of another concurrent nonmood
- psychiatric condition
- exclude alternative causes
- Maintain high index of suspicion and evaluate risk depressive factors
- Detect depressive symptoms with clinical interview and/or self-report questionnaire
- Define mood syndrome (clinical history, interview, report by spouse or significantother).
- Define potential known cause of mood syndrome (medical medications, substance abuse, and other casual nonmood psychiatric disorders).
- Treat potential causes
- Reevaluate for mood syndromes
- If mood syndrome is still present, treat as primary mood disorder
- to reduce and ultimately remove all signs and symptoms of the depressive syndrome
- to restore occupational and psychosocial function to that of the asymptomatic state
- to reduce the likelihood of relapse and recurrence
- Need for repeated medical visits to monitor response and adjust dosage.
- Unwanted side effects
- More severe (but infrequent) medication reactions, such as allergic reaction
- Potential use in suicide attempts
- Failure of many patients (10 to 30 percent) to complete treatment
- Lack of efficacy in some cases of major depressive disorder
- Need for strict adherence to the medication schedule.
- Need for continuation phase treatment
- Lack of physiologic side effects, such as those found with medication or ECT.
- Logical possibility that psychotherapy is effective for some patient for whom medication are not effective.
- Theoretical possibility that psychotherapy may make the depression less likely to recur once treatment stops because patients learn to cope with or avoid factors contributing to recurrence.
- Psychotherapy has rarely been tested in patients with severe or psychotic depressions.
- Many patients (10 to 40 percent) fail to follow through with the full treatment.
- Many time-limited forms of psychotherapy, as well as all forms of longer term psychotherapy, have not been tested for efficacy in randomized controlled trials.
- Psychotherapy is not effective for all patients with major depressive disorder.
- The quality of the therapy affects outcome.
- Therapy sessions are time-consuming and may be inconvenient.
- Psychotherapy may be expensive, depending on the type of therapy and the provider.
- Treatment effects are usually measurable later (6 to 8 weeks than with medication (4 to 6 weeks).
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