Diagnosing and Treating Mood Disorders: The Science and Ethics

1
Diagnosing and Treating Mood Disorders The
Science and Ethics
Chris Trimble, Leo Huizar, Fredah Kabbech, Megan
Sieveke, Brandon Butler
2
Mood Disorders
3
Depression

• Can refer to either
• A mood a pervasive and sustained emotional
  response
• A clinical syndrome a combination of emotional,
  cognitive and behavioral symptoms

4
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

5
Four Types of Symptoms Associated With Mood
Disorders

• Emotional
• Cognitive
• Somatic
• Behavioral

6
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

7
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

8
Somatic Symptoms

• Related to basic physiological or bodily
  functions
• Include fatigue, aches and pains, and serious
  changes in appetite or sleeping patterns

9
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

10
Diagnosing Mood Disorders

• Defined in terms of episodes
• discrete periods of time in which the persons
  behavior is dominated by either a depressed or
  manic mood

11
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

12
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

13
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

14
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

15
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

16
Types of Mood Disorders and Frequency
17
Types of Mood Disorders

• Unipolar Mood Disorders
• Major Depressive Disorder
• Dysthymic Disorder
• Bipolar Mood Disorders
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
• Subtypes

18
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

19
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

20
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).

21
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

22
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

23
Dysthymic Disorder

• No major depressive episode during the first two
  years
• Lifetime risk of 3

24
Bipolar I Disorder

• One or more manic episodes
• Lifetime risk of 1

25
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.
26
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

27
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

28
Subtypes of Mood Disorders

• 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

29
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

30
Prevalence of Mood Disorders

• Ratio of unipolar to bipolar is at least 51
• Lifetime prevalence of all mood disorders is 8,
  ranked third behind substance abuse disorders and
  anxiety disorders

31
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

32
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

33
Causes of Mood Disorders
34
Types of Causes

• Environmental Factors
• Psychological Factors
• Biological Factors

35
Environmental FactorsStress

• 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

36
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

37
Environmental FactorsChildhood 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 parents 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

38
Depression In Disease

• Estimated 1/3 people with chronic disease have
  depression.
• Alzheimers
• Boston Study
• 14 had history of depression
• HIV
• 1/3 estimated to have depression

39
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.

40
Psychological Factors

• Cognitive Vulnerability
• People responding differently to the same
  negative experience involving loss, failure and
  disappointment

41
https//www.depressionadvances.com/animation/brain
Animations.html
https//www.depressionadvances.com/animation/brain
Animations.html
42
(No Transcript)
43
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

44
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.

45
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.

46
Biological FactorsNorepinephrine

• 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.

47
Biological FactorsDopamine

• Evidence is substantial that enhanced dopamine
  activity may play a primary role in psychotic
  depression.

48
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 800a.m. and
  400p.m. for non depressed person, while a person
  with depression may have the hormone released at
  a constant level

49
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

50
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

51
Bipolar Causes
52
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.

53
(No Transcript)
54
Treatment of Mood Disorders
55
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

56
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.

57
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

58
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

59
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

60
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

61
TreatmentAntidepressants

• 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

62
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

63
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

64
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

65
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

66
Monoamine Oxidase Inhibitors

• Definitely Effective
• Atypical Depression
• Major Depression
• Dysthymia
• Melancholia
• Panic Disorder
• Bulimia
• Atypical facial pain
• Anergic Depression
• Treatment-resistant depression
• Parkinsons Disease

• Other Possible Uses
• Obsessive-complusive Disorder
• Narcolepsy
• Headache
• Chronic pain syndrome
• Generalized anxiety disorder

67
Selective Serotonin Reuptake Inhibitors

• SSRIs work by inhibiting the reuptake of
  serotonin into the neuron that made it
• Includes fluoxetine and paroxetine

68
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.

69
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.

70
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.

71
TreatmentsAntidepressants

• 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

72
TreatmentsAntidepressants

• 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

73
TreatmentsAntidepressants

• 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

74
Bipolar Treatments

• Psychiatric Management
• Acute Treatment
• Maintenance Treatment

75
Psychiatric Management

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

76
Bipolar TreatmentsLithium

• 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

77
Bipolar TreatmentsLithium

• 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.

78
Bipolar TreatmentAnticonvulsants

• 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

79
(No Transcript)
80
TreatmentsElectroconvulsive 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

81
TreatmentVagus 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

82
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

83
Side Effects of Treatments
84
Side EffectsTricyclics

• 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

85
Side EffectsTricyclics

• 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

86
Drug InteractionsTricyclics

• 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

87
Side EffectsMAIOs

• The side effects of MAOIs are generally more
  severe or frequent than for other antidepressants

88
Side EffectsMAIOs

• 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

89
Drug InteractionsMAOIs

• 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

90
Drug InteractionsMAOIs

• 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

91
Food InteractionsMAOIs

• Food Restrictions
• Avoid
• Cheese, overripe aged fruit, fava beans, sausage,
  salami, sherry, liquors, sauerkraut, monosodium
  glutamate, pickled fish, brewers yeast, beef and
  chicken liver, fermented products, red wine
• Used in moderation
• Coffee, chocolate, colas, tea, soy sauce, beer,
  other wines

• 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.

92
Side EffectsSSRIs

• 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

93
Drug InteractionsSSRIs

• 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

94
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.

95
Side EffectsSNRIs

• Nausea and vomiting
• Dizziness
• Insomnia
• Sleepiness
• Abnormal dreams
• Constipation
• Sweating
• Dry mouth

• Yawning
• Tremor
• Gas
• Anxiety
• Agitation
• Abnormal vision
• Headache
• Sexual dysfunction

96
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

97
WithdrawlsSNRIs

• 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

98
Side EffectsElectroconvulsive 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

99
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

100
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 Chriss
  aunt and sister

101
The Chris Pittman Case

• Former FDA scientist Dr. Richard Kapit, who had
  approved Zoloft for human clinical trials even
  testified in Chriss 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

102
Ethics
103
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.

104
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

105
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.

106
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.
• Schatzberg, Alan F., and Charles B. Nemeroff.
  Textbook of Psychopharmacology. 2nd ed.
  Washington American Psychiatric Press Inc.,
  1998.
• Spitzer, Robert L., Psychopathology, A case book,
  Columbia University, McGraw-Hill, Inc., 1993
• Diagnostic and Statistical Manual of Mental
  Disorders. IV txt revision ed. Washington
  American Psychiatric Association, 2000.
• "Depression Caused by Chronic Illness." Web MD.
  July 2005. WebMD Inc.. 02 Apr. 2006
  lthttp//www.webmd.com/content/article/45/1663_5121
  5.htmgt.
• "Neurotransmitter Animation." Depression
  Advances. 2006. Eli Lilly and Company. 05 Apr.
  2006 lthttps//www.depressionadvances.com/animation
  /brainAnimations.htmlgt.

107
END