M&A

Major depressive disorder is a common and serious medical illness

• negatively affects feelings, thinking and behavior

• causes feelings of sadness and/or a loss of interest in activities once enjoyed

• can lead to a variety of emotional and physical problems

• can decrease a person’s ability to function at work / home

Sadness/Grief:

• painfull feel. come in waves, often mixed with positive memories of the decreased
• self-esteem is no affected

Depression:

• Mood and/or pleasure decreased for most of two weeks
• Feelings of worthlessness / self- loathing common

When both of them co-exist togehter, then grief is more severe and last longer.

BUT: despite the overlap, they are still different!!!

x

• Separation:depressiveandbipolardisorders

• Additionof3newcategoriesofdepressivedisorders (disruptive mood dysregulation disorder, persistent depressive disorder, and premenstrual dysphoric disorder)

• Numberofbipolardisordersisunchanged

• Entityofmooddisordersnototherwisespecifiedhasbeen replaced with unspecified bipolar disorder and unspecified depressive disorder

• Criteria forepisodesofmania,hypomaniaandmajor depressions are generally unchanged with a few important exeptions

Not included in the DSM-V are the following criteria:

• B. the symptoms do not meet criteria for a mixed episode coexistence within a major depressive episode of at least 3 manic

symptoms (not sufficient to meet for manic episode) is now aspecifier
• E. The symptoms are not better accounted for by bereavement

Behavioral:....

Cognitive: ....

Emotional

Social: ...

Physical

fertig stellen (S.45)

• One or more major depressive episodes

• No manic or hypomanic symptoms

• Sudden or gradual onset

• Episodes last between 6 to 9 months

• Full recovery less likely for co-morbid personality disorders, severe episodes, psychotic features

• Half of the patients having MDD, develop second episode

• At least two months or more between episodes to count as separate

• Symptoms remain similar between episodes

siehe DSM V

oneset, course, duration:

• Beginning in adolescence (5-19y)

• Mean age at onset (30 y)

• Mean start treatment (33.5 y)

• Elderly onset

• Course is variable

• Duration variable (6-13 months)

MDE Is one of the building blocks of mood disorders but not a codable diagnosis!!!

• Must meet 5 requirements:

1) a quality of depressed mood (loss interest/pleasure)

2) has existed for a minimum period of time

3) is accompanied by a required number of symptoms

4) has resulted in distress and disability

5) violates none of the listed exclusions

Substance abuse

Physical disorsders

1. Severity:

• mild:symptoms barely fulfill criteria, little distress or interference with patient’s ability to work, study or socialize
• moderate: intermediate between mild and severe
• severe:Several symptoms more than the minimum for diagnosis, large interference with patient’s work, social or personal functioning
   

2. Remision codes:

• in partila remission:patient who formerly met full criteria and now either (1) has fewer than the required number of symptoms or (2) has had no symptoms at all, but for under 2 months.
   
• in full remission: for at least 2 MONTHS, patient has had no important symptoms of mood episode

NO additional codes for this in DSM!!!

Episode specifiers describe features of current or most recent mood episode:

• With anxious distress...

• With atypical features...

• With catatonia?!

• With melancholic features.. (extreme severe form of MDD)

• With mixed features..

• With peripartum onset...

• With psychotic features...

Specifiers that describe episode patterns:

• With rapid cycling (...s. 69

• With seasonal pattern (Mood EPISODE begin and end begin at the same time of year; seasonal episodes have been the only episodes for the last 2 years; seasonal episodes outnumber (übersteigen) the nonseasonal ones)

.

siehe bild

1. Biological models of unipolar depression:

- Animal models of D.

- The monoamine hypothesis

- Neuorchemical and Neuroanatomical Abnomalities in MDD (Hasler et al. 2004)

- Maybergs model of D. (Mayber, 1997)

- Neural circuity of D.

2. Neuroendocrine and neuroimmune interactions

3. Biological Theories

4. Psychological models of d.

- Interactional Factors

- Diathesis(Vulnerabilitäts)-Stress Model (Monroe & Simons, 1991)

5. Behavioral theories

- conditioning

- Learned Helplessness Theory (Seligmann, 1973, 1975)

- Refolumlated helplessness theory (Abrahamson, Seligman & Teasdale, 1978)

6. Cognitive Theories

Becks schema theory of d.

Becks cognitive model of d.

Becks integrative model of d.

7. Biopsychosozial models

Drugs:

SSRIs first choice

TCAs alternative to SSRIs if SSRIs

TCAs are an alternative to SSRIs if a patient has not tolerated at least two drugs from this group or is allergic to them

Duration of treatment: (checken!)

Pharmacological: at least 6 month after remission

In patients with any previous episode or the presence of residual symptoms, treatment maintained for at least 12 months after remission

In patients with more than two previous episodes, treatment maintained for at least 24 months after remission

Treatment resistance

Switching from an antidepressant to any family, including another serotonergic.

Combining antidepressants.

Augmenting the initiated treatment with lithium

ECT should be considered as a therapeutic alternative in adults with severe major depression

(siehe auch Pharmabuch)

• Largest systematic study of depression treatment (STAR*D) : 20% remai depressed after four treatments (Pigott, 2015)

• Acute phase pharmacotherapy: period between initiation of treatment and successful outcome (APA, 2000)

• Visits for clinical management during pharmacotherapy 15-30 minutes prescription of medication, symptom assessment, psychoeducation, supportive clinical management (APA, 2000)

• Selection of the specific medication based on past treatment history, cost, safety, tolerability (APA, 2000)
  50% chance that first treatment will work

1. First-generation antidepressants: TCA and MAOIs

- work by potentiating monoamine neurotransmission
- TCA inhibiting norepinephrine uptake
- MAO inhibit enzymatic degradation of norepinephrine, serotonin, DA - third / fourth line treatment when nothing else works

-MAO: strong side effects

- for atypical depression: TCA first line treatment

2. Second generation antidepressants: SSRIs, SNRIs

- SSRI first line treatment, however not more effective than TCA/MAO but easier to prescribe (APA, 2000)

- selectively inhibit 5-HT uptake transporter

- side effects: gastrointestinal symptoms, insomnia, sexual dysfunction,

- various SSRI also for anxiety disorders (Edwards & Anderson, 1999) - SNRI: second line, less tolerated,

- Buproprion: Norepinephrine and dopamine reuptake inhibitor (NDRI), does not directly affect serotonine neurotransmission (Thase & Denko, 2008)

außerdem:

Longer antidepressant therapy recommended for reducing risk of relapse or recurrence (APA, 2000)

Ensure stable and complete symptomatic remission, restauration of social functioning (APA, 2000)

High risk of relapse during the first 6 to 12 months (Thase, 2012)

• Acute assessment critical for effective treatment (Nezu et al. 2014)
• Over 280 measures of depression available (Santor, Gregus, & Welch, 2006)

• Clinician Ratings/Assessments:

  - The Hamilton Rating Scale for Depression (HAMD, Hamilton, 1960) - ”gold standard” in research & clinic
  - sem-istructured interview consisting of 21 items
  - Structured Clinical Interview for DSM-5, SCID (First et al. 2016)

• Self-report measures:
  - Beck depression inventory (BDI-II) (Beck et al. 1996)
  - The hospital and Anxiety Depression scale (HADS)
  (Zigmond & Snaith, 1983): first self-report questionnaire to measure depression and anxiety in medical, non-psychiatric patients-> useful for diverse medical disorders
  - Patient Health Questionnaire Depression Scale (PHQ-9), short (Spritzer et al. 1999)

.

sind Theorien von Beck

• Emotional feelings(PaulEckmann)

• relatively lasting emotional or affective state

• internal,subjective state,but it can often be inferred from posture or other observable behaviors

• longer experienced and more diffuse

• lack of awareness of eliciting stimulus

• can be created by stimuli of relatively low intensity or can be left behind by emotions that fade so that the initial antecedent is no longer salient

• A reaction to a stimulus that has a range of possible consequences and typically refer to discrete and intense but short-lived experiences
• A person’s temporary internal state of being, which has a clear start and end, and it is an involuntary, subjective, physiological response to an object or a situation, based in or tied to physical state and sensory feelings

x

• Major depressive disorder

• Persistent depressive disorder (dysthymia)

• Disruptive mood dysregulation disorder (<18 years)

• Premenstrual dysphoric disorder

• Depressive disorder due to another medical condition

• Substance/medication-induced depressive disorder

• Other specified, or unspecified, depressive disorder

• no manic or hypomanic episodes

• One or more major depressive episodes

• Either recurrent or single episode

• Major depressive disorder is a common and serious medical illness

• negatively affects feelings, thinking and behavior

• causes feelings of sadness and/or a loss of interest in activities once enjoyed

• can lead to a variety of emotional and physical problems

• can decrease a person’s ability to function at work / home

• Introduced DSM-III 1980

• Additional information DSM-IV

• DSM changes in subtypes

• separation of depressive and bipolare dis
• added 3 new categories: disruptive..., premenstrual..., persistent...,
• number of bipolar dis. is UNchanged
• Entity of mood disorders not otherwise specified has been replaced with „unspecified bipolar disorder”  and „unspecified depressive disorder”

• Criteria for episodes of mania,hypomania and major depressions are generally unchanged with a few important exeptions

Not included in DSM-5:

Criteria B. the symptoms do not meet criteria for a mixed episode coexistence within a major depressive episode of at least 3 manic symptoms (not sufficient to meet for manic episode) is now a specifier

Criteria E. The symptoms are not better accounted for by bereavement

S. 46

s. 49

49-56

longer than typical MDD

not severe enough for MDD

chronic

NO HIGH phases

Severity of depression is variable:
- mild chronic depression below MDD threshold vs.
- chronic mild depression punctuated by recurrent episodes of MDD ”double depression”

early: by age of 20

late: age 21 and older