“Understanding & Managing DEPRESSION”

1. “Understanding & Managing DEPRESSION” J. Subramani, M.D. and Nancy Losinno, LCSW

2. Depression

3. Depression Statistics • Lifetime prevalence Major-17% • Minor-17% • Women : Men ratio is 2:1(19 million ) • 25% of drug and alcohol problems related to depression • 30-40% of depressed individuals have sudden bouts of anger • Only 20% of depressed receiving adequate Tx.

4. Causes of Depression • Genetics : Family history could increase likelihood six-fold • Biological Factors: Neurotransmitters- Serotonin, Nor-epinephrine, Dopamine Sleep disorders Light deprivation • Reproductive Hormones: Sudden fluctuations of estrogen & progesterone

5. Emotional & Physical Signs of Depression • Depression can range from mild to severe and transitory to chronic; • Onset can occur at any age; • Can be triggered by 1 event or a series of events; • Depressed mood alone does not constitute a depressive disorder.

6. Sadness

7. Emotional Symptoms of Depression • Sadness, tearfulness, low self-esteem, obsessive self-critical thoughts, inability to experience pleasure, loss of ambition, loss of interest, inability to focus on tasks; • Irritability, anger, pessimism, guilt, helplessness, loss of hope, or feelings of despair, including thoughts of suicide.

8. Physical Signs of Depression • In the sleep realm: problems falling asleep, staying asleep or early A.M. wakening; • Appetite changes including changes in body weight; • Social withdrawal/isolation; • Increased somatic complaints, including anxiety about illness, and having many vague body complaints.

9. Child & Adolescent Depression Symptoms • Episodes last avg. 7-9 months; • Sadness, loss of interest in friends or activities, feel they are not liked/loved by others; • Feel pessimistic about the future, are indecisive, have trouble concentrating in school & may lack energy & motivation. • Usually present with more anxiety, and are reactive to family changes (divorce, abandonment or death).

10. Types of Depressive Disorders • Adjustment Disorder; • Dysthymic Disorder; • Bipolar Disorder; • Cyclothymic Disorder; • Major Depressive Disorder

11. Adjustment Disorders • Usually in response to an identifiable stressor; • In men & women, prevalence is 5-20%, condition is short-term & generally treated with talking therapy; • Continuing stressors may lengthen the persistence of the adjustment disorder.

12. Dysthymic Disorder • Chronically depressed mood that is present most of the time for at least 2 yrs in adults and 1 yr in children; • Dysthymia affects 6% of the population, esp. women; • Depressed feeling is experienced as “normal” • Untreated dysthymia and its stressors may precipitate an episode of major depression.

14. BiPolar Disorder • Mood instability which alternates between bouts of depression and episodes of mania; • Condition often begins in adolescence; • Manic episode: racing thoughts, overconfidence, talks excessively, spending binges, exaggerated or delusional ideas about abilities. • People often experience a manic episode as a relief from depression.

15. Cyclothymic Disorder • A mild form of bi-polar disorder; • Does not include psychotic thought processes; • Treatment may include psychotherapy and medication.

16. Major Depression • A serious health problem characterized by 1+ major depressive episodes; • Females carry more risk factors for depression & worry more about body image, rejection & relationship difficulties; females are also vulnerable to hormonally related mood fluctuations throughout the reproductive life cycle for which there is great stigma.

17. Depression in women

18. Major Depression in Women • Twice as many woman as men • During extreme hormonal shifts • Early puberty • 22% incidence in ages 20-45 • Perimenopausal symptom • Pregnancy –especially around wk 32 • Post partum ; 2wks- 3 months

19. Menopause

20. Depression in Men

21. Major Depression in Men • Commonly occurs with attempts to self-medicate with alcohol, drugs, food, gambling or sex; • Men often do not experience these behaviors as signs of depression and have more reluctance to ask for professional help. • Depression may be precipitated by loss of ability to function in an impt or especially valued area of life.

22. Depression & Life Changes • Even happy & eagerly anticipated events (birth of a baby, retirement, new job, etc.) can precipitate a mild depression; • The chronicity of other stressors can have a profound impact on a at-risk individual (caring for an aging parent, aftermath of divorce, job lay-off, problematic family issues)

23. Depression & Aging Issues • Increased weight gain and changes in body image; • Poor sleep habits, including undiagnosed sleep disorders; • More medications to take & MD visits to monitor meds; • Loss of friends or relatives to illness, relocation, or death; • Fears of crippling diseases, concerns for adult children, financial worries about retirement.

24. Depression & Medical Issues • Do you know that, in some at- risk people, there is a link between depression & undiagnosed diabetes? • Post-operative cardiac patients are at high risk for depression & their cardiac prognosis improves with anti-depressant use. • Untreated long term depression has an adverse effect on our immune response.

25. What About S.A.D.? • Seasonal affective disorder (SAD) affects only 1.4% of pop living in the South; and 9.7% of people living in the North. Person may crave carbohydrates (serotonin sub.) • Is a response to decreases in daylight, starting as early as August and lasting through February. • Treatment can include use of medication, increasing amount of direct sunlight, use of a lightbox, or a combination of the above.

26. A Changing Landscape • JAMA Study, 2002: N=32,000 • Kinds of Treatment Received: 1987 1997 Antedepressants 37% 75% alone Psychotherapy 71% 60% alone

27. Classes of antedepressants • SSRI’s: serotonin • NRI’s: norepinephrine • SNRI’s: serotonin/norepinephrine • Atypical: Wellbutrin: dopamine& NE Trazodone & Nefazadone Over ctr: SAMe & St. John’s

28. Role of neurotransmitters Neurotransmitters & Behavior • Serotonin: Anxiety, rumination, irritability, aggression, suicidality • Catecholamines: Anhedonia, apathy, impaired attention, low energy

29. Medications

30. Medications to Treat Depression • Depression is highly treatable, but some people may become impatient with the process (high expectations, intolerance of side effects, inability to keep med monitoring appts.) • Different “generations” of anti-depressant medications may be used • Individual variability from person-to-person; • Psychiatrist strives to use the tx dose, while minimizing side effects.

31. “Chronic” Depression • Affects a small # of those diagnosed • Usually maintained on a daily dose of meds that is monitored regularly by MD in order to reduce kindling effect; • Person needs to become aware of “buildup” pattern (rejection, overwork, poor sleep, family stress) and take active steps to intervene with MD help; • Important to develop a supportive psychotherapy relationship to minimize stress & prevent relapse.

32. Stress reduction

33. Choice of Professional • Family doctor • Psychiatrist • Psychotherapist (PhD, MSW, etc.) can’t prescribe meds • Most common source of lack of response in major depression is the administration of inadequate doses, or the use of psychotherapy alone.

34. Psychotherapy

35. The issue of suicide • No verbal threats (vague or otherwise) should be dismissed or treated lightly! • Depressed females may think about it, but depressed males have more follow-through. • Suicide more likely after former depressed person shows small improvement but now has the energy to follow-through on previous suicidal thinking.

36. Your BNL EAP Your BNL EAP Manager: Nancy Losinno avail Mon-Fri. Call X4567 to make appt. 24/7 crisis coverage provided by Magellan Behavioral health at 1-800-327-2182 or go to www.magellanhealth.com/member Employees and their household members are covered for 5 free visits to a Magellan-network provider. Call EAP Manager for referrals