DISCLOSURES

None of the faculty, planners, speakers, providers

nor CME committee has any relevant financial

relationships with commercial interest

There is no commercial support for this CME

activity

Jaswinder K. Walia, M.D.

Assistant Clinical Professor

UCR SOM, Dept of Psychiatry and Neurosciences

Associate Medical Director

RUHS BH – Western Region

Depression

Outline

Epidemiology

DSM Criteria

Types

Pathophysiology

Treatment overview

Q & A

Case

DB is a 70y/o CF w/ MDD, Passive-Aggressive PD traits

and tx non-adherence.

Seen since 2012, most recent f/u 2/2019

Case

◦ H/o Depression since her 20s

◦ Sought tx at RCMHD '85-'90, self-d/c'd b/c felt better. Was sx

free until 3/2011 when dx'd w/ breast ca and underwent

mastectomy w/in a week of dx

◦ H/o depressive sxs c/w MDD episodes

◦ No h/o mania

◦ No h/o AH/VH/PI/IOR

◦ H/o self-sabotaging behavior and passive-aggressive traits

◦ H/o intermittent passive SI consisting of "day dreams of death",

none reported in last 1y

◦ Tends to focus on Psych issues w/ PCP and DM issues in psych

office

◦ H/o good response w/ Zoloft, but chronically tx non-adherent

Case

Past Psych hx:

Psych adm x1: ITF 3/26-3/31/14 for depression and passive SI.

ETS - 11/29/11 and 12/8/11 for passive SI (also had FSBS 600).

H/o passive SI off/on

Past tx:

Zoloft 50mg qd by ETS 12/2011 - helped remit sxs.

Vistaril - helped, self-d/c'd.

Elavil ?mg + Valium 5mg qd '85-'90.

Substance use hx: none x3

Social hx: Single, lives in an indep apt since 6/10/13. IHSS 5d/wk

by PCP.

Case

PMH: Hypothyroidism (dx 11/2018), poorly controlled IDDM,

Bladder ca stage I s/p tumor resection 6/2017 w/ new recent spots

x4, h/o breast ca, s/p Rt mastectomy 3/11/11, no chemo/rad. HA1C

10 (per pt).

breast mammogram +ve 5/2018, Lt breast lumpectomy/bx on

8/1/18 neg for ca per pt

No bladder ca, ruled out by Onc in 5/2018

PCP: Dr. Kenoye Uku ("Ookoo"), Endocrine Dr. Diaz

Case

ALL: NKDA

MEDS:

Zoloft 100mg po qd

Synthroid 25mcg qam

Benazepril 2.5mg QD

OTC Ca + Vit D

OTC B-complex

OTC Vit C 1000mg qd

ASA 81mg qd

Atorvastatin 20mg po qd

Metformin 500mg bid

Novolog 70/30 20U QAM + SS tid

Lantus 70U SQ qhs

Case

Labs:

4/3/18: Lipids: chol nl, HDL 40, TG 152 CMP: glu 227,

rest nl CBC nl A1C 8.9 TSH nl B12/Folate nl UTX neg

7/13/16: Lipids: chol 203, LDL 134, HDL nl, TG nl; CMP:

glu 128, rest nl; CBC nl, TSH nl, A1C 9.2 B12/folate nl,

UTX: unable to void, to return later

7/1/15: CBC nl, TSH nl, CMP nl, Lipid nl except TG 179,

HA1C 10, B12 nl 500, TSH 3.55

Case

MSE: remarkable for:

◦ Obese (BMI 35)

◦ Rt mastectomy scar

◦ Multiple lesions, mostly old - none new, no bleed or discharge

◦ Multi old well-healed hyperpigmented lesions on b/l LE and UE,

lower legs, chest, shoulders, abdomen.

◦ Appro g+h+a. Gait steady. No PM abnl. Good eye contact. Calm,

pleasant. Speech clear/fluent. Mood "good". Affect euthymic, FR. TP

linear/goal directed. No SI/HI, intent or plan. No AH/VH/PI/IOR. AAOx4,

memory grossly intact, attn/conc nl, est intelligence avg, fund of GK avg. I

poor, J fair, IC good. Future oriented.

Case

Most recent f/u: doing well, taking meds on most days

Skin picking (legs, chest, arms, back, abdomen) continues,

no new lesions at present.

DM cont to be poorly controlled, in FBS 200-300 on

most days, in high 300s every 2-3wks and then drops to

70s x1-2/mo. Insulin and meds adjusted recently.

Case has a drawer full of multiples of all meds, including insulin. "I

have my method of numbering and how I take them."

multiples of most meds, including 4 bottles of Zoloft, all

partially full, all filled in 2016

Goes for daily walks or window shopping w/ IHSS. Goes to a

weekly Church gr. Enjoys crotchet, cross stitching and

reading. this helps her cope w/ anxiety. Feels supported by

her tx teams and church gr.

Epidemiology

Mood Disorders Prevalence : 9.5%, or 20.9 million

adults, in a given year

Median age of onset for mood disorders is 30 years.

Prevalence of all-cause depression: 6.9% in 2012 in the

U.S (NIMH)

◦ 16 million adults!

◦ Note: no exclusions were made for a major

depressive episode caused by medical illness,

bereavement, or substance use disorders.

M:F = 1:2

Depressive disorders often co-occur with anxiety

disorders and substance abuse.nimh.nih.gov

Epidemiology

Major depression one of the most common mental

disorders in the United States

Major Depressive Disorder is the leading cause of

disability in the U.S. for ages 15-44. (WHO; 2008)

MDD median age at onset is 32 years

Major depressive disorder is more prevalent in women

than in men

More than 90% of people who commit suicide have a

diagnosable mental disorder, most commonly a

depressive disorder or a substance abuse disorder.*

nimh.nih.gov

Depression - Types

Disruptive Mood Dysregulation Disorder

Major Depressive Disorder

Persistent Depressive Disorder (Dysthymia)

Premenstrual Dysphoric Disorder

Substance/Medication-Induced Depressive Disorder

Depressive Disorder Due to Another Medical Condition

Other Specified Depressive Disorder

Unspecified Depressive Disorder

Adjustment Disorder with Depressed Mood

Major Depressive Disorder

DSM -5 Diagnostic Criteria:

A) 5 or more symptoms lasting >2 wk, change from

previous functioning:

◦ Depressed mood and/or loss of interest

◦ Altered sleep, loss of energy, appetite or weight

change, feelings of worthlessness/guilt, psychomotor

changes, loss of concentration or indecisiveness,

recurrent thoughts of death/SI.

MDD

B) Symptoms cause clinically significant distress or

impairment in social, occupational, or other important

areas of function.

C) Episode not attributable to physiological effects of a

substance or medical condition.

D)Symptoms Not better explained by SAD,

Schizophreniform, Delusional D/o, or other

Schizophrenia spectrum or other psychotic disorders.

E) There has never been a manic or hypomanic episode.

MDD

Atypical presentation in the elderly:

Less sadness and feelings of guilt and more somatic

symptoms, impaired cognition and behavioral symptoms

Reversed-vegetative symptoms (e.g., hyperphagia,

hypersomnia), or leaden paralysis (heavy arms or legs)

Rejection sensitivity: a distinct, enduring pattern of

interpersonal rejection sensitivity not limited to mood

disturbances, resulting in significant social or

occupational impairment

◦ for ex: ‘my feelings are easily hurt’, ‘others do not understand

me or are unsympathetic’, and ‘others are unfriendly toward me’

MDD

Atypical presentation in the elderly:

mood reactivity (i.e., mood brightens in response to

actual or potential positive events)

Exaggerated physical symptoms – pain, GI (constipation),

insomnia

hypochondriac complaints, psychomotor

retardation/agitation

Dwelling on death themes, giving up, passive SI

At risk population

Who Tends to be Most Depressed?

CDC study found the following groups to be more likely to meet criteria for major depression:

Persons 45-64 years of age

Women

Blacks, Hispanics, non-Hispanic persons of other races or multiple races

< high school education

those previously married, recently widowed

individuals unable to work or unemployed

persons without health insurance coverage

Of note: similar patterns were found among persons with "other depression" with the two following exceptions:

=> adults aged 18-24 yrs most likely to report "other depression" as were Hispanics (instead of other non-Hispanics)

At risk population

Other factors:

Presence of physical illness, esp chronic pain

Use of multiple drugs

Existence of psychosocial stressors

Presence of brain white matter changes

Variables Late onset

depression

Early onset

depression

Rate of

cardiovascular

diseases

High Low

Familial depression Low High

Comorbid

psychiatric disease

Low High

White matter

abnormality

High Low

Executive

dysfunction

High Low

Suicide High Low

Apathy and

psychomotor

changes

High Low

late onset depression and early onset depression

Anatomic Changes

Structural neuroimaging in patients with

longstanding or untreated depression shows

Increased ventricular-brain ratio

Smaller frontal lobe volumes

Smaller hippocampal volume

Brain Activity

Neuroimaging shows altered function during depression and

changes that occur after treatment

A review of functional imaging studies (regional cerebral

blood flow, glucose metabolism, positron emission

tomography, single photon emission computed tomography,

and functional magnetic resonance imaging) found evidence

suggesting several brain regions are involved in the

pathophysiology of depression, including…

frontal and temporal lobes along with parts of the striatum,

pallidum, and thalamus

The anterior cingulate cortex and the subgenual prefrontal

cortex

altered activity in the amygdala

Neurobiological Changes in MDD

Other Changes

Sleep and circadian rhythms

Changes in sleep architecture during depression include decreased

=> REM latency

=> Slow-wave sleep

Diurnal variation in symptoms

Blunted circadian rhythms may involve body temperature, blood pressure, pulse, plasma cortisol, norepinephrine, thyroid stimulating hormone, and melatonin

Hypothalamic-pituitary-adrenal axis

It is thought that overproduction of corticotropin

releasing hormone causes excess activity of the

hypothalamic-pituitary-adrenal cortex axis in many

depressed patients

Prolonged or excessive secretion of glucocorticoids

may lead to suppression of neurogenesis and

hippocampal atrophy

Neurotransmitters

Monoamines (serotonin, norepinephrine, and

dopamine)

Gamma-aminobutyric acid (GABA)

Glutamate

Some Medical causes of Depression

Textbook of

Psychiatry, Fifth

Edition. The

American

Psychiatric

Publishing.

Substances as causes of Depression

Textbook of

Psychiatry, Fifth

Edition. The American

Psychiatric Publishing.

Interventions

Coordinate medical care with PCP and other Specialists

Identify and treat underlying medical causes

Involve family and caretakers

Groups, Therapy: role transitions, grief, dependency,

support

Medications / ECT

Depression – Med Treatment

Textbook of Psychiatry, Fifth Edition. The American Psychiatric Publishing.

Depression Tx Cont’d

Textbook of Psychiatry, Fifth Edition. The American Psychiatric Publishing.

Recovery Model Challenges the idea that severe mental illness is chronic

and that stability is the best one could hope for.

Recovery = reclaiming a meaningful life, going BEYOND

stability.

SAMHSA (Substance Abuse and Mental Health Services

Administration): “A process of change through which

individuals improve their health and wellness, live a self-

directed life, and strive to reach their full potential”.

-adaa.org Anxiety and Depression Association of America

-samhsa.gov

Recovery Model

The American Association of Community Psychiatrists

(AACP): recovery is “a personal process of growth and

change, which typically embraces hope, autonomy, and

affiliation as elements of establishing satisfying and

productive lives in spite of disabling conditions or

experiences”

Guidelines: replace paternalistic, illness-oriented

perspectives with collaborative, autonomy-enhancing

approaches

Recovery Model – Basic Principles

Per SAMHSA, Recovery:

Based on HOPE

Person-driven: Self-determination and self-direction

Occurs via many pathways: Individuals/lives are unique

Holistic: it encompasses an individual’s whole life,

including mind, body, spirit, and community.

Supported by peers and allies: Mutual support

Supported through relationship and social

networks: the presence and involvement of people who

believe in the person’s ability to recover; who offer

hope, support, and encouragement; and who also

suggest strategies and resources for change.

samhsa.gov

Recovery Model Principles

Culturally-based and influenced: values, traditions, and

beliefs are keys in determining a person’s journey and

unique pathway to recovery.

Supported by addressing trauma: foster safety (physical

and emotional) and trust, as well as promote choice,

empowerment, and collaboration.

Involves individual, family, and community strengths and

responsibility: serve as a foundation for recovery.

Based on respect: Community, systems, and societal

acceptance and appreciation for people affected by

mental health and substance use problems – including

protecting their rights and eliminating discrimination –

are crucial in achieving recovery.

adaa.org Anxiety and Depression

Association of America

Please feel free to contact Socorro with an question you may have

Socorro Guerrero

Program Coordinator

Geriatric Medicine Division

Socorro.Guerrero@ruhealth.org

(951) 486-5623