​Kembara Xtra - Medicine - Depression

​Kembara Xtra - Medicine - Depression 
Introduction 

A main mood illness characterized by an ongoing loss of interest or pleasure in
a sense of melancholy and/or a diminishing interest in many or most things
activities that were formerly enjoyed (anhedonia), which represents a loss of
shift from the functionality that came before

The study of epidemiology, including incidence and prevalence. 

Incidence
8.1% of adults over the age of 20 in the United States fall into this category.
experienced depression throughout a specific time of two weeks between the
2013 and 2016.
● 19.2% lifetime risk of experiencing serious depressive disorder
(MDD)

Prevalence
Among adults of all racial and ethnic groups, non-Hispanic Asians had the lowest rate of
depression (3.1%), compared to Hispanic (8.2%) and non-Hispanic whites (11.4%).
White Hispanics make up 7.9% of the population, while non-Hispanic blacks make up 9.2%.
adults. This tendency was noticed not only in men but also in women.
women.
Across all racial and Hispanic-origin groupings, with the exception of non-Hispanic whites,
Hispanic Asian men, in particular, exhibited a much lower prevalence of the condition.
when compared with women's rates of depression.

The incidence rate goes down as the number of family members increases
earning opportunities for men and women alike.

The most common age group is those in their early teens, with the lowest risk.
prevalence among younger adults and adolescents


Causes and effects: etiology and pathophysiology 

Regarding the pathophysiology, there are many different schools of thought;
none proven
Genetics
When multiple gene loci are involved, the risk to an individual is enhanced.
in the presence of environmental stressors; research on twins show.
37% concordance.


factors of danger 
● Female > male (2:1)

The seriousness of the initial attack
● Persistent sleep disturbances
The presence of one or more chronic diseases, a recent myocardial infarction, or both
infarction (MI), cardiovascular accident (CVA)
• A significant history of mental illness in the family (depression, bipolar disorder, suicide,
misuse of substances), partner suffering from depression
Abuse and traumatic experiences during childhood
● Substance abuse and dependence, domestic
abuse/violence
● Losses, stressors, unemployment
Not married, no longer married, or married but unhappy

Conditions That Often Occur Together 

Disorders of the bipolar spectrum, the cyclothymic spectrum, mourning reactions, and
anxiety disorders, somatoform disorders,
schizophrenia/schizoaffective disorders
● Medical comorbidity
Abuse of various substances

Diagnosis 

The following requirements are necessary to diagnose MDD according to DSM-5:
Criteria A: Five of the Following Symptoms Must Be Present Nearly All the Time:
each day during the course of the same two-week period, with a minimum of one
among the five, four were symptoms of depression, one was a lack of interest, and one was both.
pleasure:
- Subjective report of feeling depressed for the majority of the day or
observations made by other individuals
- A discernible reduction in interest or pleasure derived from any and all activities
the majority of the day based on reports or observations made by individuals.
from other individuals
- Alterations in appetite, including loss or gain of a large amount of weight
loss despite not following a diet or gaining weight
- Insomnia or hypersomnia
- Fatigue or energy loss
- Restlessness, agitation, or a slowing of the body or the speech
actions that can be observed by others
- Feelings of worthlessness and remorse that are excessive or inappropriate
- Problems with thinking and concentrating, a weak memory, and
indecisiveness
- Recurrent ideas of ending one's own life, suicidal tendencies, or
a suicide attempt or a premeditated plan to end one's life
Criteria B: The presence of symptoms that cause considerable social,
distress or impairment in one's job or functional duties.
Criteria C: the presence of symptoms that cannot be attributed to a substance
symptoms, or any number of other medical conditions
HISTORY
The acronym "SIGECAPS" is a useful mnemonic device.
Sleep: Variations from the baseline in the habits associated with sleep, including
issues with sleeping too much, waking up too early, or being unable to get asleep at all
Interest: a diminishing desire to participate in formerly pleasurable pursuits
(anhedonia)
Guilt refers to an excessive or improper sense of guilt, which may or may
not be associated with a particular complication or set of circumstances
Energy: a sense of having insufficient energy
Problems with concentration include an inability to focus on particular activities
Appetite entails a rise in appetite or a fall in appetite.
Psychomotor: agitation and restlessness, or the perception of either of these
that the typical routines of daily life are too taxing to be handled
Suicidality is defined as the urge to take one's own life or to inflict physical harm on oneself.
internalized ideas of negativity that are repeated incessantly
feelings of homicidal intent or suicidal ideation

Considerations Regarding the Aged

● Often difficult to detect due to medical comorbidities
Can manifest itself in the form of memory problems
The Geriatric Depression Scale (GDS 15) has been shown to significantly enhance the rate of
diagnosis in primary care setting.
Considerations Relating to Children
Can manifest with somatic symptoms (such as headaches and gastrointestinal distress),
irritation or hostility, trouble concentrating in school, and
a significant amount of time spent away from school or an unexpected shift in
grades

The Patient's Clinical Examination 
A complete assessment of the patient's physical and mental health
The subject's current state of consciousness and orientation

Appearance: cleanliness, proper posture, and appropriate attire
Attitude: animosity and a lack of interest
Behavior, which may include eye contact, psychomotor agitation, or
retardation
A state of mind such as being sad, nervous, furious, happy, tearful, etc.
● Affect: mood-congruent, flat, labile, manic, etc.
a memory that is complete on all levels: immediate, recent, and distant
Fluency, repetition, and comprehension are three important aspects of speech.
Processes of thought and the content of such thoughts: the presence of delusions,
hallucinations, thoughts of suicide or homicide, and a flight of ideas are all symptoms of schizophrenia.
or grandiosity, tangentiality, obsessive compulsive behaviors, etc.
gaining a grasp of one's own disease is an insight.
Judgment: the ability to choose courses of action that are logical

Differential Diagnosis 

Conditions related to mental health:
- If you or someone you know is experiencing the depressive phase of bipolar disorder,
manic episodes, a personal or familial history of manic-depressive illness,
previous excitement or agitation while taking an antidepressant
medication
- Disturbance of adjustment accompanied by a gloomy mood
— Mood problems that are associated to substance abuse
A number of coexisting medical conditions, including adrenal disorders, hypothyroidism, and
hypercalcemia, diabetes, failure of the liver or the kidneys,
cancer, sleep difficulties, chronic fatigue syndrome, and other conditions
fibromyalgia, lupus
Disorders of the nervous system or the brain, such as
neurodegeneration CNS disease, dementia, or delirium
● Deficiencies: vitamin B3, vitamin B12, or folate

Results From the Laboratory 
The Patient Health Questionnaire-9, also known as the PHQ-9, is a short questionnaire.
screening test that can be used to diagnose major depressive disorder in primary care
settings. If your score is 10 or higher, you may be suffering from depression.
is presumably present.

Other scales that have been proven accurate are the Beck Depression Inventory,
The GDS 15, also known as the Zung Self-Rating Depression Scale.
Initial Tests (lab, imaging)
To rule out medical factors
CMP to assess the functionality of the kidneys and liver

Additional Examinations, as well as Other Important Factors
● TSH
● CBC
Think about getting a urine drug test if your symptoms indicate it.
drunkenness, or something alarming that happened historically.

Management 

Treatment guidelines recommended by the American Psychiatric Association (APA) in 2010
a recommendation from the guideline is as follows:
The acute phase, which lasts for the first three months of treatment
- Thorough assessment, taking into account the potential danger to both the individual and others, with
the selection of an appropriate setting for treatment. The goal ought to
be completely free of any symptoms.
For those with mild to severe symptoms of depression, either
It would be beneficial to try counselling and/or medication.
Medication and talk therapy are both effective treatments for severe or refractory depression.
and psychotherapy are the recommended treatments.
Those who are at risk of causing harm to themselves or others are recommended to be hospitalized.
if the patient is unable to care for him or herself or others because of their condition,
be unable to care for oneself or if there is no one else to care for them
a network of support to help with the treatment.
- Schedule an appointment between 2 and 4 weeks after beginning treatment, and then every 2 weeks thereafter. 
until there is an improvement, then monthly after that.
- Continue to increase dosage q3–4wk until remission. Full
In between four and six weeks, the drug will begin to take effect.
The addition of a second drug can be considered an
necessary.
- It is recommended that you go in for monitoring six times if you are younger.
patients, especially those who are at a high risk of suicide, should see a doctor within the first week.
, as well as do so frequently).
The continuation phase, which might last from four to nine months.
phase of treatment) and the maintenance phase (nine or more months of treatment)
- Check for a relapse every three to six months if you are stable.
- Make use of depression rating scales in conjunction with patient narratives in order to
monitor response.
Those people who do not react favorably to medicine by alone
The addition of psychotherapy is recommended.
- Dosing should be continued even after remission has been achieved.
for a minimum of six to nine months with the goal of reducing the risk of relapse; cognitive-behavioral
cognitive behavioral therapy (CBT) is also useful in the reduction of
relapse (visits are usually scheduled every two weeks).
- The dosage of medication should be progressively decreased (weeks to
months) in order to make it possible to identify patterns of reoccurring
symptoms and to reduce the likelihood of discontinuation syndromes occurring.

Measures of a General Nature 

Psychotherapy
Combined behavioral and cognitive therapy (CBT) is an integrative form of
therapy; its efficacy has been demonstrated (NNT = 2.75)
In interpersonal psychotherapy (IPT), a trigger of a patient's
the depressed episode, which helps with grieving and promotes health.
The recognition of impacts helps to overcome role disagreements and role conflicts.
transformations, as well as the development of social skills
Psychodynamic psychotherapy: a treatment approach utilized to
thoughts that aren't conscious that are influencing current conduct
Marriage and family therapy: focuses on a couple's relationship with their
issues relating to interpersonal connections
Components of CBT and DBT are incorporated into problem-solving therapy.
IPT into a condensed treatment schedule consisting of six to twelve sessions; may
play a role in those who exhibit only a few modest symptoms of sadness
Supportive psychotherapy: increases one's sense of self-worth,
emphasis on one's psychological functioning as well as one's adaptive skills
on existing connections that are unhealthy or maladaptive.
patterns of emotional and/or behavioral responses to situations
As a first treatment for unipolar major depression, the following:
Think about engaging in psychotherapy either on its own or in tandem with other treatments.
with the aid of medication.

Medication 

Begin with the smallest amount that is offered and work your way up to the highest
dose that has been approved by the FDA and has been well tolerated for at least four to six
weeks before concluding that it was useless. The essence of efficiency is
selection criteria are comparable both within and within medication groups.
should be based on the familiarity of the physician with the patient
preferences and qualities including the following:
Analysis of risks and potential adverse effects
Concomitant diseases as well as medicines taken at the same time
Isolated manifestations of depression
Ease of usage (number of dose intervals), or the cost.
● Patient preference
First Line
SSRIs are the brand name for selective serotonin reuptake inhibitors.
name): initial dose; typical dose [special remarks]

● Citalopram (Celexa): 20 mg/day; 20 to 40 mg/day (FDA
(caution: dosages of more over 40 mg/day may increase the risk of QT prolongation)
● Escitalopram (Lexapro): 10 mg/day; 10 to 20 mg/day
(causes dose-dependent QTc prolongation)
● Fluoxetine (Prozac): 20 mg/day; 20 to 40 mg/day (FDA
authorized for adolescents)
Fluvoxamine (Luvox): 50 mg every four to six hours; 50 to 200 mg per day (off)
term for depression; most commonly used for obsessive compulsive disorder)
● Paroxetine (Paxil): 20 mg/day or Paxil CR 25 mg/day; 20 to
40 mg/day or Paxil CR 50.0 to 62.5 mg/day
Sertraline (Zoloft): 50 mg per day, with a range of between 50 and 200 mg per day
Sexual dysfunction accounts for twenty percent of all reported side effects.
symptoms such as nausea, gastrointestinal distress, dizziness, sleeplessness, headache, and weight gain
gain. In most cases, adverse effects disappear by the end of the first
week.
The onset of withdrawal symptoms is possible after a sudden cessation of use
(i.e., dizziness, nausea, headache, paresthesia).

Things to Think About When Expecting
Selective serotonin reuptake inhibitors, or SSRIs, including fluoxetine,
Both sertraline and bupropion are quite popular and studied medications.
safe. After 20 weeks of pregnancy, there is a higher chance of complications.
pulmonary hypertension; mild transitory newborn syndrome caused by pulmonary hypertension
CNS; as well as motor, respiratory, and gastrointestinal manifestations.
Paroxetine (pregnancy Category D): There is mixed evidence regarding its safety.
the available evidence concerning the possibility of congenital heart problems
as well as other congenital abnormalities throughout the first trimester of pregnancy.
There is a possibility that infants born to women who take antidepressants would display a
brief period during which withdrawal symptoms are present.

.Second in Rank
Antidepressants known as tricyclic antidepressants (TCAs) and tetracyclic antidepressants
- Amitriptyline** (Elavil): 25 to 50 mg twice daily; 100 to 300 mg per day
mg per day (inhibitor of serotonin reuptake, not norepinephrine reuptake)
- Amoxapine (Asendin): 25 mg every four hours or three times a day; 200 to 300 mg per day
norepinephrine is superior to serotonin reuptake inhibitors at a daily dosage of mg.
- Clomipramine** (Anafranil): 25 mg QHS or TID; 100 to
250 milligrams per day (serotonin reuptake superior to norepinephrine reuptake)
inhibitor)
- Desipramine** (Norpramin): 25 mg daily; 150 to 300 mg once every other day.
mg per day (may be stimulating for some, sedative for others)
others)
- Doxepin** (Sinequan): 25 mg QHS up to 150 mg/day;
150 to 300 milligrams per day (very sedating and leads to weight gain)
gain)
- Imipramine** (Tofranil): 25 mg QHS or 150 mg/day; 150
up to 300 mg per day (serotonin reuptake inhibitors > norepinephrine reuptake inhibitors)
inhibitor)
- Maprotiline** (Ludiomil): 25 mg QHS; 100 to 225 mg
(Quinoxaline hydrochloride) QHS is a strong norepinephrine reuptake inhibitor.
- Nortriptyline (Pamelor): 25 mg QHS; 50 to 150 mg/day
(norepinephrine was more effective than the serotonin reuptake inhibitor)
- Protriptyline (Vivactil): 5 mg QHS up to 5 mg TID; 10 mg QHS up to 10 mg TID; 15 mg QHS
to 60 mg once every four hours (which is better tolerated due to the drug's low affinity for
receptors for H1 and M1)
- Trimipramine** (Surmontil): 25 mg QHS; 150 to 300
mg per day of an inhibitor of serotonin reuptake
**Drugs have a sedative effect on the user and are linked to weight gain.
gain.
– Effectiveness comparable to that of SSRIs; nonetheless, the therapy is constrained by
negative consequences (1) [C].
- Steer clear of use if any of the following comorbidities are present:
a variety of serious heart conditions, including arrhythmias.
seizure disorders, osteoporosis, glaucoma.
- Most frequently observed side effects include orthostatic hypotension and dry mouth.
mouth, hazy vision, constipation, urine retention, and a dry feeling in the throat and chest.
tachycardia, confusion/delirium
Serotonin regulators and modulators
- Nefazodone (Serzone): 100 mg BID; 300 to 600 mg/day
(not typically utilized due to the elevated risk of liver failure)
- Trazodone (Desyrel/Trialodine): 50 mg BID; 200 to 400
- Vilazodone (Viibryd): 10 mg QHS titrated to 20 mg QHS
beginning with week 2, take 20 to 40 mg per day (with food)
- The recommended dosage of vortioxetine (Trintellix) is 5 to 10 mg per day or 20 mg per day.
- Common adverse effects include drowsiness, lightheadedness, and
sexual dysfunction, gastrointestinal issues such as constipation or diarrhea
MAOIs, or monoamine oxidase inhibitors, are the drugs in question.
- Phenelzine (Nardil): 15 mg twice daily (TID) after an initial dose of 15 mg once day
throughout the course of two to three days; 60 to 90 mg every day
- Selegiline (Eldepryl): 6 milligrams every 24 hours; 6 to 12 milligrams every 24 hours
- Tranylcypromine (Parnate): 10 mg/day; 30 to 60 mg/day
- Common side effects include low blood pressure and sexual dysfunction
dysfunction, disruption to one's sleep

Alert
Warning in bold: increased likelihood of suicidal thinking and behavior in
young children, teenagers, and adults younger than 25 years of age
years who are being given antidepressants for treatment. Although
This has not been expanded to include adults, who are at risk of suicide.
It is necessary to do assessments on every single patient.
Serotonin syndrome: an extremely uncommon but possibly fatal condition
complications resulting from a sudden increase in dose or the introduction of a new factor
medicine that has serotonergic effects on the patient.
Those taking antidepressants run the risk of having manic episodes triggered by the medication.
has an illness known as bipolar. Caution is advised when using if a personal or
The past of the family.
TCAs have the potential to be lethal in high doses.
Give yourself a 14-day break from any and all antidepressants prior
beginning MAOIs.
ISSUES FOR REFERRAL
Notify authorities right away in the event that there is an active suicidal plan or
self-harming purpose, severe self-neglect, or a considerable risk of harming oneself are all required.


Additional 

Patients with severe conditions may benefit from electroconvulsive treatment (ECT).
depression that is resistant to treatment or severe depression with psychotic symptoms
characteristics of catatonia and patients with an immediate requirement for
response (such as being suicidal or having nutritional deficiencies).
● Repetitive transcranial magnetic stimulation (rTMS) may
be beneficial for depression that does not respond well to therapy.

Surgical Methods and Operations 

Deep Brain Stimulation and Deep Cortical Stimulation are two terms that refer to the same thing.
therapies under investigation for patients with chronic depression.

Alternative Medicine 
Lacking oversight from the FDA
Hypericum perforatum, also known as St. John's wort: 300 to 1,800 milligrams
mg/day
Light therapy has been shown to be useful in the treatment of seasonal affective disorder.

Admission 
Patients who are at an increased risk of taking their own lives should be treated as inpatients.

Ongoing Medical Attention 
Clinical depression is a prevalent condition that can be successfully treated and
not a flaw in one's character.
It is possible that medications will need to be taken for at least two to four weeks.
weeks before any signs of a positive effect become apparent. It may take 6
to 8 weeks in order to reach its maximum level of effectiveness.
Recommend getting regular exercise, practicing healthy sleep hygiene, eating well, and
reduced amounts of cigarette and alcohol consumption.
800-273-TALK is the number to call for the National Suicide Prevention Lifeline.
(8255) is a toll-free number that is available at any time.

Prognosis 

Seventy percent of them demonstrate significant improvement.
50% will experience a relapse at some point during their lifespan.