Alex Padikken 4 th Year Pharmacy Student Florida A&M University Disease State presentation.

DEPRESSION

Alex Padikken4th Year Pharmacy Student

Florida A&M UniversityDisease State presentation

Objective

• Define Depression • Discuss the signs and symptoms• Discuss risk factors, prevalence and

pathophysiology• Describe the components of diagnosis and

treatment options.

Definition

• Depression is defined as intense feelings of sadness, mental slowing, hopelessness, despair, pessimistic worry, agitation, self-deprecation and inability to experience pleasure during usual activities.

Prevalence

• 6.7% of US adults experience major Depressive disorder each year.

• Women are 70% more likely than men to experience depression.

• Average age of onset is 32 years old. • Non-Hispanic blacks are 40% less likely than

Non-Hispanic whites to experience Depression.

Signs and Symptoms

• Fatigue• Feeling of Hopelessness• Feeling “empty” • Irritability• Restlessness

• Decreased energy• Difficulty concentrating• Appetite loss• Insomnia• Thoughts of suicide

Risk Factors

• Gender: Female• Having biological relatives with Depression• Abusing alcohol or any illicit drugs• Having traumatic experiences as a child• Depressed previously• Having serious medical conditions such as

Parkinson's disease, dementia, stroke, HIV/Aids.

Etiology

• The cause of depression are not well understood.

• Combination of genetic, biologic and environmental factors.

Pathophysiology

• Due to an alteration in neuronal and synaptic catecholamine concentration at adrenergic receptor sites in the brain, deficiency of catecholamine, especially NE and

5-HT

Depressed VS Not Depressed

Depression Diagnosis• DSM IV

– Diagnostic and statistical manual of mental disorder • At least five symptoms from the following list during the same

two week period– Depressed mood– Marked diminished interest– Significant weight loss or weight gain– Insomnia or hypersomnia– Psychomotor agitation or retardation– Fatigue or loss of energy– Feelings of worthlessness– Diminished ability to concentrate– Recurrent suicidal ideation

Types of Depression

• Major Depression• Dysthymic Disorder• Minor Depression• Postpartum Depression• Seasonal affective Depression

Major Depression

• Combination of symptoms interfering a person’s ability to:– Work– Sleep– Study– Eat– Pleasurable activities

Dysthymic Disorder

• Characterized by long term symptoms that prevents a person's normal functioning or well being.

Minor Depression

• Characterized by having symptoms for 2 weeks or longer that do not meet full criteria for major depression.

Postpartum Depression

• This is a common type of depression that occurs in new mothers. It often occurs between two weeks and six months after delivery.

Seasonal affective Depression (SAD)

• This type of depression is related to changes in seasons.

Non-Pharmacological Treatment

• St. John’s Wort– Not approved by FDA– Classified as a dietary

supplement– Associated with many

significant drug interactions

• Omega 3 fatty acids– Supplement may ease

depression– Used in addition to other

standard depression treatment.

Non-Pharmacological Treatment

• Psycotherapy– Cognitive-behavioral

therapy (CBT) – Interpersonal therapy

(IPT)

• Electroconvulsive Therapy– Formerly known as

“shock” therapy.

Treatment Options

• SSRI– SSRIs block the

reabsorption of the neurotransmitter serotonin in the brain

– Most commonly prescribed antidepressants.

– Ease symptoms of moderate to severe depression

– Relatively safe and fewer side effects.

• Citalopram (Celexa)• Escitalopram (Lexapro)• Fluoxetine (Prozac)• Paroxetine (Paxil)• Sertraline (Zoloft)• Fluoxamine (luvox)

SIDE EFFECTS: reduced sexual desire, weight gain or weight loss, N/V, GI issues.

Treatment Options

• SNRI– block the absorption of

the neurotransmitters serotonin and norepinephrine in the brain.

– Effective at easing depressive symptoms

– Similar to SSRI

• Duloxetine (Cymbalta)• Venlafaxine (Effexor XR)• Desvenlafaxine (Pristiq)

SIDE EFFECTS: N/V, Sexual dysfunction, dry mouth, also increase BP.

Treatment Options

• Tricyclics– Block the absorption of the

neurotransmitters serotonin and norepinephrine

– Block Ach and histamine receptors

– Earliest antidepressants developed

– Adjunctive analgesics for chronic pain conditions, such as trigeminal neuralgia

– Childhood enuresis (imipramine)

• Amitriptyline (elavil)• Desipramine (Norpramin)• Doxepin (sinequan)• Imipramine (Tofranil)• Nortriptyline (Pamelor)• Protriptyline (Vivactil)• Trimipramine (Surmontil)

SIDE EFFECTS: Dry mouth, blurred vision, urinary retention, constiption, weight gain, vivid dreams

Treatment Options

• MAO-Is– Inhibit MAO and cause

accumulation of 5- HT, NE and DA in CNS and Periphery

– Highly effective– Disadvantage: potential

to cause hypertensive crisis when taken with tyramine

– Use is limited due to dietary restrictions

• Isocarboxazid (Marplan)• Phenelzine (Nardil)• Selegiline (Emsam)• Tranylcypromine

(Parnate)

SIDE EFFECTS: Dry mouth, headache, dizziness, drowsiness, insomnia

Additional Agents

• Bupropion (Wellbutrin)

• Mirtazapine (Remeron)

• Trazodone (Oleptro)

• Nefazodone

• DA and NE reuptake inhibitors

• NE and 5HT reuptake inhibitors

• Inhibits 5HT reuptake and alpha 1-adrenergic and histamine blocker

• Similar to Trazadone but less sedating and increased risk of hepatotoxicity

Special Population

• Pediatric Patients– Childhood depression is very common– Only FDA approved medication is Fluoxetine

• Elderly patiets– SSRIs are the first line therapy– Age 65 and older have the highest suicide rate

Clinical pearls

• All antidepressant comes with a black box warning

• Benefit of the medication start within 1-2 weeks

• It takes 6-8 weeks to see the full drug effect• SSRIs and SNRIs are considered first line

treatment options

Pharmacist Role

• Dispense Medication Guide and instruct patients to read it

• Counsel on lag time and the need to take it daily as with other agents

• Counsel the patients on side effects• Counsel the patient to avoid abruptly

discontinuing the antidepressants without consulting the physician.

References• Mann JJ. The Medical Management of Depression. N Engl J Med 2005;353:1819–

1834.• O'Connor EA, Whitlock EP, Beil TL, Gaynes BN. Screening for depression in adult

patients in primary care settings: a systematic evidence review.Ann Intern Med . 2009 Dec 1;151(11):793-803.

• Association AP. Practice guideline for the treatment of patients with major depressive disorder (revision). American Psychiatric Association. Am J Psychiatry 2000; 157: 1-45.

• U.S. Preventive Services Task Force. Screening for depression in adults: U.S. preventive services task force recommendation statement. Ann Intern Med . 2009 Dec 1;151(11):784-92.

• Staff, Mayo Clinic. "Definition." Mayo Clinic. Mayo Foundation for Medical Education and Research, 10 Feb. 2012. Web. 02 Oct. 2013.

• Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials.JAMA . 2007 Apr 18;297(15):1683-96.

QUESTIONS ???