Depression
From Standard of Care
A heterogeneous process, with a variable course, inconsistent response to treatment and of unknown cause (Belmaker RH).
Associated with somatic, behavioral and emotional symptoms.
Associated with impaired energy, sleep, concentration and dysregulation of appetite (Gelenber AJ).
Physical inactivity and comorbid depressive disorders occur commonly in the chronically ill.
5-12% of men and 10-25% of women have major depressive episodes during their lifetime.
One of the most common mental disorders in late life.
Lifetime risk of developing major depressive disorder in the US is 16.2% (Kessler RC).
Lifetime incidence of depression is more than 20% in women and 12% in men.
Major depressive disorders affects approximately 14.8 million adults, and about 6.7% of the US population aged 18 years and older in a given year(Kessler RC et al).
2-5% of community dwelling adults age 65 years and older have criteria for the diagnosis of major depression.
As many as 10% of older adults in primary care and 30 to 50% in institutional and long-term care facilities are clinically depressed.
When not successfully treated may become a persistent problem in as many as 40% of older adults.
Risk of depression 2 to 3 times higher among women compared to men.
Common in patients with chronic medical illness, persistent insomnia, functional decline associated with aging, in individuals who have experienced stressful life events and social decline.
Associated with increased risk of chronic illnesses and mortality and conversely chronic illnesses increased the risk of depression.
Depressive symptoms associated with impaired adherence to prescribed treatments, impaired quality of life, increased symptom burden, disability and functional and roll impairment and increased use of healthcare services.
Prevalence of depression is greatest in women during childbearing age.
2 to 3 times higher in first-degree relatives of depressed persons.
In a given year about 10% of the U.S. population older than 18 years have a depressive disorder.
6-9% of older patients have a major depressive disorder.
Seizures are common in depressed individuals and patients with seizures are more likely to be depressed.
As many as 10% of patients over the age of 65 years in primary care practices have significant depression.
Elderly patients with major depression are at high risk for recurrence disability and death.
17-37% of older patients have mild depressive symptomatology.
35-70% of primary care patients with depression do not receive a diagnosis or receive inadequate treatment.
When patients present with somatic complaints primarily, as do two-thirds of those presenting to a primary physician, the diagnosis is frequently missed (Timonen M).
More than 80% of patients with depression improve when they receive appropriate treatment with medication, psychotherapy, or the combination.
About 70% of depressed patients do not receive treatment.
When elderly cease driving they increase symptoms of depression for a period of up to 6 years.
Diagnostic criteria for major depression-Diagnostic and Statistical Manual of Mental Disorders: five or more of the following:
depressed mood most of the day nearly every day
markedly diminished interest or pleasure in all or almost all activities
clinically significant weight loss in the absence of dieting or weight gain of more than 5% in body weight in a month or a decrease in appetite
insomnia or hypersomnia
observable psychomotor agitation or retardation
fatigue or loss of energy
feelings of worthlessness or excessive or inappropriate guilt
diminished ability to think or concentrate, or indecisiveness
recurrent thoughts of death, recurrent suicidal ideation without a specific
plan, a specific plan for committing suicide, or a suicide attempt
Diagnosis is a clinical one.
Initial screening for depression: Patient Health Questionnaire 2-during the last month, have you often been bothered by feeling down, depressed, or feeling hopeless? and During the past month, have you often been bothered by little interest or pleasure in doing things?
Positive answers to both of the Patient Health Questionnaire 2 is associated with a diagnostic sensitivity for depression of 96% and a specificity of 57% (Whooley MA, Arroll B).
Negative Patient Health Questionnaire responses make the diagnosis of depression unlikely (Williams JW Jr.).
Patient Health Questionnaire response positive to one question should prompt additional questions to establish the presence of major depression and the presence of at least 4 more symptoms for at least 2 weeks along with social and occupational impairment is required to make the diagnosis.
About 15% of depressed patients are refractory to all known types of therapy.
In the presence of medical problems is associated with higher morbidity and mortality rates compared with nondepressed patients with medical problems.
Associated with increased risk for the development of cardiovascular events in healthy patients, and for recurrent problems in patients with established coronary disease and for adverse outcomes after coronary artery bypass surgery.
Associated with increased rate of coronary heart disease and myocardial infarction.
Three times more common after myocardial than in the general community, and its presence increases the risk of CV events and mortality.
Among patients with cardiovascular disease preexisting depression and anxiety occurs on average 17 years before the cardiovascular event, and independently predicts hospitalizations (Chamberlain AM et al).
Associated with significant increased risk of stroke morbidity and mortality.
Depression may contribute to stroke through neuroendocrine, and immunological, and inflammatory effects.
Depression is associated with C-reactive protein, IL-1, and Il-6, and these inflammatory factors have been associated with increased risk of stroke.
Depression is associated with poor health behaviors such as smoking, physical inactivity, poor diet, poor medication compliance, and obesity, which may increase the risk of stroke.
Independently associated a increase in risk of congestive heart failure among older patients with isolated hypertension.
Common comorbidity in patients with chronic heart failure, with a reported incidence of approximately 48% in this population.
Depression in patients with heart failure associated with increased mortality and hospitalization.
A negative prognostic factor for patients with coronary artery disease.
Prevalence in people diagnosed with cancer ranges between 22-29%.
As many as 70% of patients with depression have a MTHFR polymorphism and require additional CNS L-methylfolate.
Patients with MTHFR polymorphism have reduced CNS L-methylfolate and are 4 times more likely to develop depression.
Depressed individuals with low CNS L-methylfolate are 6 fold less likely to respond to antidepressant agents and 13 times more likely to relapse.
High risk of relapse after discontinuation of antidepressant therapy.
Women's Health Initiative (WHI) study indicated that antidepressant therapy maybe detrimental with respect to stroke and total mortality in a large cohort of postmenopausal women.
Associated with an increased risk of type 2 diabetes.
Depression associated with a 60% increase in risk of type II diabetes (Mezuk B et al).
Diabetes increases the risk of depression.
Depression in diabetics associated with increased risk of dementia.
Depression twice as common in diabetics than in comparison and nondiabetic groups.
Higher consumption of chocolate associated with depression.
Associated with alterations in hypothalamus pituitary adrenal axis function with increased secretion and flattened circadian rhythm of cortisol.
Folate deficiency has been associated with depression and may impair the response to antidepressants and may contribute to relapse of depression.
Folate supplementation may improve depression.
It is suggested that an impaired corticosteroid receptor function is responsible for hyperactivation of the hypothalamic pituitary adrenal axis.
In women of childbearing age most commonly treated with selective serotonin reuptake inhibitors which have not been associated with increased risk of congenital malformations.
Minor depression refers to depressive symptoms that fail to rise to the standard of 4 or more symptoms beyond depressed mood and anhedonia.
Treatment options: watchful waiting, psychopharmacological treatment, and psychotherapy.
Exercise reduces depressive symptoms among individuals with chronic illness.
Patients with mild to moderate depression and who undergo exercise training have the largest improvement in functional outcomes and achieve the largest antidepressant effects (Herring MP et al).
