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Diagnosing and Treating Mood Disorders: The Science and Ethics. Chris Trimble, Leo Huizar, Fredah Kabbech, Megan Sieveke, Brandon Butler. Mood Disorders. Can refer to either: A mood: a pervasive and sustained emotional response

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slide1
Diagnosing and Treating Mood Disorders: The Science and Ethics

Chris Trimble, Leo Huizar, Fredah Kabbech, Megan Sieveke, Brandon Butler

depression
Can refer to either:

A mood: a pervasive and sustained emotional response

A clinical syndrome: a combination of emotional, cognitive and behavioral symptoms

Depression
how to distinguish depression from normal sadness
How To Distinguish Depression From Normal Sadness
  • The mood change is pervasive across situations and persistent over time
  • The mood change may occur in the absence of any precipitating events
  • The depressed mood is accompanied by impaired ability to function in usual social and occupational roles
  • The change in mood is accompanied by a cluster of additional signs and symptoms
  • The nature or quality of the mood change may be different from that associated with normal sadness
emotional symptoms
Emotional Symptoms
  • Depressed or dysphoric mood is the most common and obvious symptom of depression
  • People who are depressed describe themselves as feeling utterly gloomy, dejected and despondent
  • Manic patients experience euphoric like symptoms
cognitive symptoms
Cognitive Symptoms
  • Involve changes in the way people think about themselves and their surroundings
  • Depressed people may have trouble concentrating and are easily distracted
  • Preoccupation with guilt and worthlessness
  • Manic patients report sped up thoughts and ideas
somatic symptoms
Somatic Symptoms
  • Related to basic physiological or bodily functions
  • Include fatigue, aches and pains, and serious changes in appetite or sleeping patterns
behavioral symptoms
Behavioral Symptoms
  • Changes in the things that people do and the rate at which they do them
  • Psychomotor retardation often accompanies the onset of depression
  • Manic patients show energetic, provocative and flirtatious behavior
diagnosing mood disorders
Diagnosing Mood Disorders
  • Defined in terms of episodes
    • discrete periods of time in which the person’s behavior is dominated by either a depressed or manic mood
major depressive episode
Major Depressive Episode
  • Five or more of the following symptoms must have been present during the same two week period and represent a change from previous functioning
  • At least one of the symptoms is either
    • Depressed mood
    • Loss of interest or pleasure
major depressive episode symptoms
Depressed mood most of the day, nearly every day

Diminished pleasure in all, or almost all activities

Significant weight loss (without dieting) or weight gain

Insomnia or hypersomnia nearly every day

Psychomotor agitation or retardation

Fatigue or loss of energy

Feelings of worthlessness or guilt

Diminished ability to think or concentrate

Recurrent thoughts of death or suicidal ideation

Major Depressive Episode Symptoms
manic episode
Manic Episode
  • A distinct period of abnormally and persistently elevated, or expansive mood, lasting at least one week
  • During the period of mood disturbance, three of more of the following symptoms have persisted and have been present to a significant degree
manic episode symptoms
Inflated self esteem or grandiosity

Decreased need for sleep

More talkative than usual

Flight of ideas

Distractibility (drawn to unimportant stimuli)

Increase in goal directed activity

Excessive involvement in pleasurable activities that have a high potential for painful consequences

Manic Episode Symptoms
mood disorders15
Mood Disorders
  • Two primary types:
    • Unipolar mood disorder: the person experiences only episodes of depression
    • Bipolar mood disorder: the person experiences episodes of mania as well as depression
types of mood disorders
Unipolar Mood Disorders

Major Depressive Disorder

Dysthymic Disorder

Bipolar Mood Disorders

Bipolar I Disorder

Bipolar II Disorder

Cyclothymic Disorder

Subtypes

Types of Mood Disorders
major depressive disorder
One or more major depressive episodes

No manic or unequivocal hypomanic episodes

Lifetime prevalence of 15%

Major Depressive Disorder 15% suicide mortality

VA 1991 Study

Major Depressive Disorder mortality 38.7%

13% no psychiatric monitoring

Major Depressive Disorder
major depressive disorder19
Major Depressive Disorder
  • Course is variable
    • Some having episodes years apart, clusters of episodes, and some with frequent episodes throughout life
    • Only about 20% have chronic episodes
  • After the first episode, 50%- 60% chance of a second , and a 5%-10% chance of a manic episode (i.e. developing bipolar I disorder)
  • After second episode, 70% chance of a third
  • After third episode, 90% chance of a fourth
  • The greater number of previous episodes is an important risk factor for recurrence
major depressive disorder20
Major Depressive Disorder
  • By definition, Major Depressive Disorder cannot be due to:
    • Physical illness, alcohol, medication, or street drug use.
    • Normal bereavement.
    • Bipolar Disorder
    • 7Mood-incongruent psychosis (e.g., Schizoaffective Disorder, Schizophrenia, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified).
major depressive disorder co occurring disorders
Major Depressive DisorderCo-occurring Disorders
  • Substance Abuse
  • Anxiety
    • 80 to 90% of individuals with Major Depressive Disorder also have anxiety symptoms (e.g., anxiety, obsessive preoccupations, panic attacks, phobias, and excessive health concerns).
  • Cancer, COPD (Chronic Obstructive Pulmonary Disease), Pain, eating disorders
  • Causation:
    • Meds: steroids
    • Diseases: hypothyroidism
dysthymic disorder
Dysthymic Disorder
  • Depressed mood for at least two years
  • Never without at least two of the following symptoms for more than two months
    • Poor appetite or overeating, insomnia or hypersomnia, low energy, low self esteem, poor concentration, feelings of hopelessness
dysthymic disorder23
Dysthymic Disorder
  • No major depressive episode during the first two years
  • Lifetime risk of 3%
bipolar i disorder
Bipolar I Disorder
  • One or more manic episodes
  • Lifetime risk of 1%
slide25
These positron emission tomography scans of the brain of a person with bipolar disorder show the individual shifting from depression, top row, to mania, middle row, and back to depression, bottom row, over the course of 10 days.
bipolar ii disorder
Bipolar II Disorder
  • One or more major depressive episodes
  • At least one hypomanic episode
    • A hypomanic episode is a less severe version of a manic episode.
  • No manic episodes
subtypes of mood disorders
Subtypes of Mood Disorders
  • Melancholia: describes a particularly severe type of depression
  • Psychotic features: when hallucinations or delusions were present during the most recent episode
  • Rapid cycling: the person experiences at least 4 episodes within a 12 month period
subtypes of mood disorders28
Postpartum Onset: when episodes begin within 4 weeks after childbirth

Seasonal affective disorder: when the onset of episodes is regularly associated with changes in seasons

Subtypes of Mood Disorders
prevalence of mood disorders
Prevalence of Mood Disorders
  • Depression accounts for more than 10 percent of all disabilities in the US
  • Younger generations are experiencing higher rates of depression, and those who become depressed are doing so at an earlier age
  • Depression affects 13-14 million people each year
prevalence of mood disorders30
Prevalence of Mood Disorders
  • Ratio of unipolar to bipolar is at least 5:1
  • Lifetime prevalence of all mood disorders is 8%, ranked third behind substance abuse disorders and anxiety disorders
gender differences
Gender Differences
  • Women are two or three times more vulnerable to depression than men
    • Sex hormones, stressful life events, childhood adversity, etc
    • May be more likely to seek treatment
    • May be more likely to be labeled as depressed
  • No differences seen in bipolar disorders
children statistics
Children Statistics
  • Up to 2.5% of children in the US suffer from depression
  • Up to 8.3% of adolescents in the US suffer from depression
  • Girls entering puberty are twice as likely to experience depression as boys
types of causes
Types of Causes
  • Environmental Factors
  • Psychological Factors
  • Biological Factors
environmental factors stress
Environmental Factors:Stress
  • Levels of stress may vary from person to person.
  • Depressive episodes can make a person more vulnerable to further episodes, so small amounts of stress can activate depression
    • “Learner Helplessness”- after experiencing chronic or repeated stressful events, people can learn to feel helpless
environmental factors substance abuse
Environmental Factors: Substance Abuse
  • Depression that is a result of drug abuse, medication, or toxin exposure
  • Associated with use and withdrawl from: alcohol, amphetamine, cocaine, hallucinogens, inhalants, opioids, phencyclidine, sedaitves, hypnotics and anxiolytics
  • Exposure or habitual use of chemicals can alter brain structure and function resulting in depression
environmental factors childhood difficulties
Environmental Factors:Childhood Difficulties
  • Depression can develop in children who have experienced a traumatic event including but not limited to:
    • Death of family member or friend
    • Natural disaster
    • Divorce
    • Loss of parent’s job, home, etc...
  • Many of these children are emotionally damaged or lack emotional development and often have difficulties adjusting
  • Traumatic Event may affect the development of the Limibic System
depression in disease
Depression In Disease
  • Estimated 1/3 people with chronic disease have depression.
  • Alzheimer’s
    • Boston Study
      • 14% had history of depression
  • HIV
    • 1/3 estimated to have depression
continued
Continued…
  • The rate for depression occurring with medical illness*:
    • Heart attack: 40-65%
    • Coronary artery disease (without heart attack): 18-20%
    • Parkinson's disease: 40%
    • Multiple sclerosis: 40%
    • Stroke: 10-27%
    • Cancer: 25%
    • Diabetes: 25%

*Reviewed by the doctors at The Cleveland Clinic Department of Psychiatry and Psychology.

psychological factors
Psychological Factors
  • Cognitive Vulnerability
    • People responding differently to the same negative experience involving loss, failure and disappointment
slide41
https://www.depressionadvances.com/animation/brainAnimations.html

https://www.depressionadvances.com/animation/brainAnimations.html

biological factors
Biological Factors
  • Neurotransmitters and Neurons
    • The signal enters the neuron through the dendrite and proceeds through the cell body to the axon where it is switched from a electric signal to a chemical one
    • Theses chemical signals are called neurotransmitters
      • Neurotransmitters can fit into many receptors, but receptor sites can only receive specific transmitters
      • Upon release the transmitter is broken down by mono amine oxidase (MAO) or its taken back in by the neuron that released it, called “reuptake”
biological factors44
Biological Factors
  • Of the 30 or so known neurotransmitters, depression effects Serotonin, Norepinephrine, and Dopamine
  • Depression has been linked to both low and elevated Norepinephrine concentrations.
biological factors serotonin
Biological Factors: Serotonin
  • The permissive hypothesis of serotonin function postulates that the deficit in central serotonergic neurotransmission permits the expression of bipolar disorder but is not sufficient to cause it.
    • According to this theory, both the manic and the depressive phases of bipolar illness are characterized by low central serotonin function but differ in high versus low norepinephrine activity.
biological factors norepinephrine
Biological Factors:Norepinephrine
  • The catecholamine hypothesis of affective disorders proposes that some forms of depression are associated with a deficiency of catecholamine activity (particularly norepinephrine) at functionally important andrengeric receptor sites in the brain, whereas mania is associated with a relative excess.
biological factors dopamine
Biological Factors:Dopamine
  • Evidence is substantial that enhanced dopamine activity may play a primary role in psychotic depression.
biological factors hormones
Biological Factors: Hormones
  • About one half of all depressed persons have a high level of the hormone cortisol in their blood
  • A person with a depressive mood disorder may not have their hypothalamus regulating the cortisol production in the adrenal gland correctly
  • Normal cortisol levels peak at 8:00a.m. and 4:00p.m. for non depressed person, while a person with depression may have the hormone released at a constant level
biological factors genetics
Biological Factors: Genetics
  • There is a 1.5 to 3% greater chance for a person to develop a depressive disorder if a parent or sibling has it as well
    • 50% of those with bipolar disorder have a parent with history of clinical depression
    • 25% of children of a parent who is bipolar develop a depressive disorder
    • 50-75% of children of two parents with bipolar disorder develop a depressive disorder
biological factors twin studies
Biological Factors: Twin Studies
  • If one twin develops depression there is a 76% chance that the other twin will develop a disorder as well
    • When raised apart the percentage is 67%
    • Because this number is not closer to 100%, there is indication that other factors are also responsible
  • Fraternal twins have a 19% chance of developing a depressive disorder if the other develops one
causes of depression
Causes of Depression
  • Depression has been linked to size/function in the temporal and frontal lobes and the cingulate gyrus. However, it is unclear as to whether the depression causes the abnormalities or the depression is a result of the abnormalities.
treatments
Treatments:
  • Unipolar Mood Disorders
    • Cognitive Behavioral Therapy
    • Antidepressant Medication
  • Bipolar Mood Disorders
    • Lithium
    • Anticonvulsant Medication
    • Psychotherapy
  • Others
    • Electroconvulsive Therapy
    • Vagus Nerve Stimulation
    • Transcranial Magnetic Stimulation
cognitive behavioral therapy
Cognitive Behavioral Therapy
  • CBT combines both cognitive therapy and behavioral therapy
    • Cognitive Therapy teaches a person how certain thinking patterns are causing their symptoms-by giving them a distorted picture of what's going on in their life, and making them feel anxious, depressed or angry for no good reason, or provoking them into ill-chosen actions.
cognitive behavioral therapy57
Cognitive Behavioral Therapy
  • Behavioral Therapy helps patients weaken the connections between troublesome situations and their habitual reactions to them. It also teaches them how to calm their mind and body, so they can feel better, think more clearly, and make better decisions
cognitive behavioral therapy58
Cognitive Behavioral Therapy
  • Identification of Skill Deficits:
    • Help patient to identify deficits so that they can learn better ways to manage life
  • Evaluation of Life-Experiences
    • Help patient develop realistic expectations about life, and help distinguish between what the patient needs and what they want
  • Self-talk
    • Help patient identify negative self-talk, teach them how to combat these thoughts and to replace them with positive thought
cognitive behavioral therapy59
Cognitive Behavioral Therapy
  • Automatic thoughts
    • Help patient identify negative automatic thoughts and ways to replace these thoughts with positive ones
  • Irrational ideas and Beliefs
    • Teach patient how to identify their irrational thoughts and how to differentiate between irrational and rational thought
  • Overgeneralizing and Catastrophizing
    • Help patient identify and change negative overgeneralizations
cognitive behavioral therapy60
Cognitive Behavioral Therapy
  • Cognitive Distortions
    • Help patient determine what evaluations are distortions by providing objective feedback of their evaluations of the world
  • Pessimistic Thinking
    • Help patient develop more optimistic view of world
treatment antidepressants
Treatment:Antidepressants
  • Four types of drugs are used in the treatment of depression and other associated mood disorders:
    • Tricyclic antidepressants
    • Monoamine Oxidase Inhibitor
    • Selective Serotonin Reuptake Inhibitors
    • Serotonin Norepinephrine Reuptake Inhibitors
tricyclic antidepressants
Tricyclic Antidepressants
  • From 1960s until late 1980s, tricyclic antidepressants represented the major pharmaceutical treatment for depression
  • They still provide the surest antidepressant response for moderately to severe depression
tricyclic antidepressants63
Tricyclic Antidepressants
  • TCAs work by increasing the concentration of norepinephrine and serotonin in certain regions of the CNS
  • TCAs impede the reuptake of norepindephrine and serotonin
  • They are safe and effective for up to 80% of patients
tricyclic antidepressants64
Tricyclic Antidepressants
  • There are two broad chemical classes:
    • Tertiary Amines
      • They have a greater effect in boosting serotonin than norepinephrine.
        • amitriptyline, imipramine, trimipramine and doxepin
    • Secondary Amines
      • Greater increase of norepinephrine levels
        • nortriptyline, desipramine, and protriptyline
monoamine oxidase inhibitors
Monoamine Oxidase Inhibitors
  • MAOIs treat depression by inhibiting the effect of monoamine oxidase which causes the concentrations of serotonin, norepinephrine and dopamine to increase
  • Most doctors will not prescribe MAOIs unless a patient is not responding to other antidepressants
monoamine oxidase inhibitors66
Definitely Effective

Atypical Depression

Major Depression

Dysthymia

Melancholia

Panic Disorder

Bulimia

Atypical facial pain

Anergic Depression

Treatment-resistant depression

Parkinson’s Disease

Other Possible Uses

Obsessive-complusive Disorder

Narcolepsy

Headache

Chronic pain syndrome

Generalized anxiety disorder

Monoamine Oxidase Inhibitors
selective serotonin reuptake inhibitors
Selective Serotonin Reuptake Inhibitors
  • SSRIs work by inhibiting the reuptake of serotonin into the neuron that made it
  • Includes fluoxetine and paroxetine
serotonin norepinephrine reuptake inhibitors
Serotonin Norepinephrine Reuptake Inhibitors
  • This class of drugs is most recent addition to the family of antidepressants and has a structure and chemical profile that distinguishes them both tricyclic antidepressants and SSRIs.
  • Work by increasing levels of Serotonin and Norepinephrine by inhibiting their re-absorption back into the cell.
venlafaxine
Venlafaxine
  • Venlafaxine inhibits serotonin and norepinephrine reuptake without significant effects on muscarinic, cholinergic, histaminic, or alpha-andrenergic receptors.
  • Therefore, venlafaxine activity is similar to tricyclics and SSRIs but has a less adverse side-effect profile.
bupropin
Bupropin
  • Bupropin is the newest drug for treating depression, although the exact neurochemical mechanism is not known
    • Does not inhibit monoamine oxidase or inihibit the reuptake serotonin and norepinephrine
    • Does inhibit the reuptake of dopamine to some extent
  • It is a stimulant type drug that is used in the treatment of major depression.
treatments antidepressants
Treatments:Antidepressants
  • 50-65% of people given an antidepressant show much improvement over 3 months, compared to 25-30% of people given a placebo.
    • Indicates that although drug is effective, antidepressants, like most medicines, may have some benefits due to placebo affect
treatments antidepressants72
Treatments:Antidepressants
  • Medication must be used every day or at every time prescribed. If not taken correctly treatment will not be effective and may have adverse effects.
  • Antidepressants will usually take 1-2 weeks work, however some may take up to six weeks
treatments antidepressants73
Treatments:Antidepressants
  • On the basis of clinical research and experience, the consensus is that most people can be taken off their antidepressants after six to eight months of clinical response without doing worse than patients continuing on the drug
bipolar treatments
Bipolar Treatments
  • Psychiatric Management
  • Acute Treatment
  • Maintenance Treatment
psychiatric management
Psychiatric Management

At this time, there is no cure for bipolar disorder; however, treatment can decrease the associated morbidity and mortality.

bipolar treatments lithium
Bipolar Treatments:Lithium
  • Lithium is prescribed to people with bipolar disorder to even out the “highs” and “lows.”
  • Because bipolar disorder requires long term treatment, a patient may have to take Lithium for many years, often in combination with other antidepressants
bipolar treatments lithium77
Bipolar Treatments:Lithium
  • Lithium interferes with the synthesis and reuptake of chemical messengers by which nerves communicate with each other (neurotransmitters). Lithium also affects the concentrations of tryptophan and serotonin in the brain.
  • Lithium's effects usually begin within one week of starting treatment, and the full effect is seen by 2 to 3 weeks.
bipolar treatment anticonvulsants
Bipolar Treatment:Anticonvulsants
  • Often prescribed to patients who do not respond to lithium
  • Include carbamazepine (Tegretol) or valproic acid (Depakene)
  • More than 50% respond positively to these drugs
  • Reduce the frequency and severity of relapse
treatments electroconvulsive therapy
Treatments:Electroconvulsive Therapy
  • Patient is put to sleep and temporarily paralyzed, so that their muscles do not contract and cause injuries like fractures. An electric current is then run through the brain to initiate a seizure.
  • ECT is sometimes the most effective, rapid method of treating severe major depressive disorder (MDD).
    • for patients with poor response to medications,
    • poor tolerance of usual antidepressants,
    • severe vegetative symptoms,
    • or psychotic features
treatment vagus nerve stimulation
Treatment:Vagus Nerve Stimulation
  • VNS stimulates the limbic system, a group of related structures that affect mood, motivation, sleep, appetite, alertness and other factors commonly altered by depression.
  • VNS is delivered to the left cervical vagus nerve by the NeuroCybernetic Prosthesis (NCPâ) System which is implanted just under the skin in the left chest area.
    • Delivers a pre-programmed, intermittent electrical pulse to cervical vagus nerve 24 hours a day
transcranial magnetic stimulation
Transcranial Magnetic Stimulation
  • TMS is a procedure in which the electrical activity in the brain is influenced by a magnetic pulse.
  • This procedure can be used to alter function of certain areas of the brain, especially those involved in depression
side effects tricyclics
Initially:

they cause blurred vision

Constipation

Light-headedness when standing or sitting up suddenly

Dry mouth

Difficulty urinating

Feelings of confusion

Cognitive Dysfunction

A small percentage of people will have other side effects such as:

sweating, a racing heartbeat, low blood pressure, allergic skin reactions or sensitivity to the sun.

Side effects usually disappear once therapeutic effects if medication take hold

Side Effects:Tricyclics
side effects tricyclics85
Side Effects:Tricyclics
  • More serious side effects, although rare, can be aggravation of narrow angle glaucoma and seizures
  • Some tricyclic side effects relate to the fact that these medications have similar effects on other neurotransmitters in the CNS, notably histamine and acetylcholine
drug interactions tricyclics
Drug Interactions:Tricyclics
  • Drug Interaction
  • MAOIs Stroke, hypertension
  • Norepinephrine Large increase in blood pressure and incidence of arrhyhmias
  • Phenothiazines Psychosis, agitation
  • Barbiturates Increase heteocyclic metabolism
  • Cimetidine Blocks metabolism of heterocyclics
  • Haloperidol Can block metabolism of heterocyclics
  • Methylphanidate Blocks metabolisms of heterocyclics
side effects maios
Side Effects:MAIOs
  • The side effects of MAOIs are generally more severe or frequent than for other antidepressants
side effects maios88
Drowsiness

Constipation

Nausea

Diarrhea

Stomach upset

Fatigue

Dry mouth

Dizziness

Low blood pressure

Lightheadedness, especially when getting up from a lying or sitting position

Decreased urine output

Decreased sexual function

Sleep disturbances

Muscle twitching

Weight gain

Blurred vision

Headache

Increased appetite

Restlessness

Shakiness

Trembling

Weakness

Increased sweating

Side Effects:MAIOs
drug interactions maois
Drug Interactions:MAOIs
  • Because of the extensive inhibition of monoamine oxidase by MAOIs enzymes raises the potential for a number of drug interactions.
    • Many of these interaction occur with over-the-counter medications
drug interactions maois90
Drug Interactions:MAOIs

Drug Interaction

Other MAOIS Increase risk for side effect; covulsions

TCAs, Carbamazepine, Hypertension; convulsions

Cyclobenzaprine

SSRIs Serotonin Syndrome

Stimulants (dextromamphetamine); Increased blood pressure

Busirone

Meperidine Potentially fatal interaction

Dextromethorphan Brief psychosis

Direct Sympathomimetics Increased blood pressure

Indirect Sympathomimetics Hypertensive crisis possible

Oral Hypoglycemics (insulin) May worsen hypoglycemia

Fenfluramine, L-Tryptophan Serotonin Syndrome possible

food interactions maois
MAOIs inhibit monoamine oxidase in gut that is responsible for the break down of tyramine. A build up of tyramine can lead to a sudden increase in blood pressure and a chance of heart attack or stroke.

Food Restrictions

Avoid:

Cheese, overripe aged fruit, fava beans, sausage, salami, sherry, liquors, sauerkraut, monosodium glutamate, pickled fish, brewer’s yeast, beef and chicken liver, fermented products, red wine

Used in moderation

Coffee, chocolate, colas, tea, soy sauce, beer, other wines

Food Interactions:MAOIs
side effects ssris
loss of appetite, weight loss

increased appetite, weight gain

allergic reactions

dry mouth

irritability / anxiety

sleeplessness

drowsiness

headache

shaking

dizziness

fits / convulsions

disturbance of sexual function (but this is also a feature of depression)

sweating

bruising

manic or hypomanic behaviour

shaking

dizziness

fits / convulsions

disturbance of sexual function (but this is also a feature of depression)

sweating

bruising

manic or hypomanic behaviour

abnormal movements

low sodium level

suicidal ideas

abnormal movements

low sodium level

suicidal ideas

Side Effects:SSRIs
drug interactions ssris
Drug Interactions:SSRIs
  • Although the potential for interaction does exist, SSRIs are not associated with many of the interactions are seen with other antidepressants
    • Paroxetine and fluvoxamine have been associated with increased bleeding when given with wafarin
    • Does not effect Lithium levels
suicide and ssris
Suicide and SSRIs
  • There is evidence that the use of antidepressants, especially SSRIs, can cause an increase in suicidal thoughts, however it does not show an increase in cases.
    • A severely depressed patient, or those with bipolar syndrome in a “low” phase, usually only have the energy to focus on their low. As the medication begins to take affect they will have an increase in energy and suicidal thoughts as they transition from their “low” or depressed episode. It is this time when the patient is still in a “depressed state of mind,” that they are able to think more about and idealize suicide because oh their higher energy level.
side effects snris
Nausea and vomiting

Dizziness

Insomnia

Sleepiness

Abnormal dreams

Constipation

Sweating

Dry mouth

Yawning

Tremor

Gas

Anxiety

Agitation

Abnormal vision

Headache

Sexual dysfunction

Side Effects:SNRIs
side effects bupropin
Side Effects: Bupropin
  • 28% of patients will lose five pounds or more
  • 0.04% of patients will experience seizures
    • Common: Agitation, constipation, diarrhea, dizziness, dry mouth, headache, increased perspiration, insomnia, nausea, vomiting
    • Rare: Acne, blurred vision, chest pains, chill, coordination problems, confusion, decrease in white blood cell count, fainting, fever,hair color change
withdrawls snris
Withdrawls:SNRIs
  • Stopping treatment with SNRIs, especially when done suddenly, can cause withdrawal-like symptoms:
        • nausea, vomiting, anxiety, diarrhea, agitation, confusion, headaches, nightmares, coordination changes, or skin-tingling or shock-like sensations
          • Sometimes referred to as discontinuation syndrome
side effects electroconvulsive therapy
Side Effects:Electroconvulsive Therapy
  • Anxiety or nervousness
  • Gastrointestinal distress (nausea and diarrhea)
  • Headache
  • Insomnia
  • Rash
  • Slight weight loss
  • Sexual impotence in men (about 10%)
  • Lose of interest in sex for both men and women; inability to achieve orgasm
the chris pittman case
The Chris Pittman Case
  • In 2001, the 12 year boy shot and killed his grandparents while being under the influence of Zoloft, a popular antidepressant for the previous couple of days
the chris pittman case100
The Chris Pittman Case
  • Defense attorneys argued that Chris suffered adverse reactions to the drug including akathisia (a neurological reaction characterized by extreme internal restlessness, which has been associated with suicide and violence), emotional blunting, mania and psychosis with testimonies by Chris’s aunt and sister
the chris pittman case101
The Chris Pittman Case
  • Former FDA scientist Dr. Richard Kapit, who had approved Zoloft for human clinical trials even testified in Chris’s defense stating that some antidepressants can alter the behavior of people under 18, causing mania and even suicide
  • Chris was charged and sentenced as an adult on February 15, 2005, and is now serving 30 years in prison
ethics103
Ethics
  • Ethical issue arises over a depressed patients ability to make decisions concerning treatment.
  • An elderly patient that has been diagnosed with depression has recently become gravely ill, requiring dialysis.
ethics104
Ethics
  • If you are not given an effective dosage of antidepressant medication, suicide rates increase. Is the hit-or-miss method of treatment with medication ethical?
  • Untreated Depression has a high risk of suicide that accompanies the disorder
ethics105
Ethics
  • 54% of patients with bipolar disorder are misdiagnosed as having depression
  • Misdiagnoses and treatment of patients with bipolar disorder as having a unipolar disorder can magnify the patients symptoms
      • Many antidepressants can cause a patient with bipolar disorder to have exaggerated and prolonged “highs” and “lows”
  • Should we be quick to treat Depression with medication when misdiagnosis can have serious consequences.
references
References
  • Downing-Orr, Kristina. Rethinking Depression - Why Current Treatments Fail. 1st ed. New York: Plenum Press, 1998.
  • Higgins, Edmund S. "Is Depression a Neurochemical or Neurodegenerative?." Current Psychiatry 3.9 (2004): 39-40.
  • Kline, Nathan S., M.D., Factors in Depression, Rockland State Hospital, Raven Press Books, Inc., 1974
  • Lazarus, Jeremy A. "Ethics in Split Treatment." Psychiatric Annals 31.10 (2001): 611-614.
  • Oltmanns, Thomas F., Case studies in Abnormal Psychology, 3rd, John Wiley and Sons, Inc., 1991
  • Oltmanns, Thomas F., and Robert E. Emery. Abnormal Psychology. 5th ed. Upper Saddle River: Prentice Hall, 2004.
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