Depressive Disorders

From a 2014 lecture by Dr Katie Strack (FM):
Depressive disorders – DSM 5 update:
Disruptive mood regulation disorder
 – new dx
 – avoids overdiagnosis of “bipolar”
 – can be used <12 yo – teenagers and adults don’t qualify
 – persistent irritability and frequent episodes of extreme behavior
 – must be developmentally inappropriate
Pearl re: pseudodementia vs pre-dementia.  Pre-dementia causes patient frustration with memory loss.  Pseudodemented patients just don’t care.
Depression doesn’t always manifest as sadness – can be angry or irritable.
Loss of interest or pleasure almost always present, but don’t necessarily have to be sad or “down.”
Persistent depressive disorder:  combines chronic MDD and dysthymia, for > 2 years (adolescents > 1 year).
What Goes On In Therapy:
Three Targets:  Emotions, Beliefs and Behavior within the context of Relationship (the therapeutic one and outside relationships).  All therapeutic approaches address one or more of these realms.
Also a helpful approach to assessing patients:
1.  What emotions are they expressing?
2.  What beliefs underlie their actions and emotions?
3.  What are their behaviors?
>>> Meditation works by opening up the gap between me and my emotions/beliefs (which I’ve overly identified with) and to teach me that emotions/beliefs (thoughts) can arise, even strong ones, without needing to act/behave based on them.
Depression rests on the false belief that “this will never end.”  >>> Thus, the helpful tenant of Buddhism that nothing lasts forever, everything is transient.
Medications:
SSRIs
 – citalopram can be both activating and sedating
 – citalopram, fluoxetine, paroxetine and sertraline all increase seizure risk
 – all cause GI upset and sexual side-effects
 – weight gain with citalopram, escitalopram and some others.
SNRIs
TCAs
 – desipramine and nortriptyline have the least anticholinergic effects
other (buproprion, mirtazapine (sedating, weight gain), trazodone (sedating))
atypical antipsychotics
Serotonin Syndrome:  from SNRIs, SSRIs and other serotonergic drugs (tramadol).  Tx is benzos, supportive care, discontinuation of offending meds.
Best to taper off most SSRIs, by 25% per week if able.
Other adjuncts:  exercise, relaxation, positive activities, etc.
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