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20.06.2015

Different types of depression scales, feeling fatigued often - PDF Review

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One way to avoid the possible adverse effects of pharmacotherapy is to treat women who suffer from postpartum depression with psychotherapy. The time course of depression and anxiety in relation to childbirth is more complex than that of postpartum psychosis, the blues, or the highs.
Research and discussion of peripartum affective disorders still focuses most on postpartum depression.
Anxiety follows a similar pattern to depression: most women who are anxious postpartum are also anxious while pregnant.
It is possible that those women vulnerable to depression during pregnancy have different HPA axis function from those vulnerable to postpartum depression. Bloch and colleagues16 have provided the best evidence so far for a role for sex hormones in the generation of postpartum depression. Research into hormonal prophylaxis and treatment of postnatal depression and psychosis is limited.
Several studies have shown that postpartum depression is more common in women positive for thyroid autoantibodies, independent of thyroid hormone dysfunction, but the basis of this association is unclear.17-19 In these studies, depression was usually assessed over the course of the whole postpartum year, and its time of onset did not appear to be closely associated with the time of parturition.
Postpartum psychosis has a strong genetic component, probably including both a joint vulnerability with manic depression in general, and a specific vulnerability to a puerperal trigger. ABSTRACT: Depression in the elderly significantly affects patients, families, and communities. Depression is the most common mental health problem in the elderly[1] and is associated with a significant burden of illness that affects patients, their families, and communities and takes an economic toll as well.
Because of our aging population, it is expected that the num­ber of seniors suffering from depression will increase. The Geriatric Depression Scale (GDS) is a well-validated screening tool for depression in the elderly that comes in two common formats: the 30-item (long form) and 15-item (short-form) self-rating scale.
TreatmentThe current Canadian practice guidelines for the treatment of depression in the elderly were developed by the Canadian Coalition for Seniors’ Mental Health (CCSMH) in 2006.[1] They were created by experts in the field, are evidence-based, and include both pharmacological and nonpharmacological strategies. Note that most depression studies have been conducted on younger populations, and when mixed-aged groups have been studied older adults have been underrepresented. Choice of antidepressantFortunately there are several antidepressants that have been shown to be efficacious in elderly patients being treated for a major depressive episode without psychotic features.
Given the side effect profile and high rates of drug-drug interactions, monoamine oxidase inhibitors (MAOIs) are not considered first- or even second-line agents for depression in the elderly.
It is also important at each visit to monitor for any worsening of depression, emergence of agitation or anxiety, as well as for suicide risk, especially in the early stages of treatment. Treatment to remissionAccording to the current CCSMH guidelines, if there is no improvement in depressive symptoms after 4 weeks or insufficient improvement in symptoms after 8 weeks on the maximum recommended or tolerated dose of an antidepressant, then the antidepressant should be changed. If there is significant improvement but not full remission after 4 weeks on the optimized antidepressant, the recommendation is to wait another 4 weeks and then consider add-on treatment if remission is still not achieved.[1] Add-on options include either an antidepressant of a different class, another agent such as lithium, or psychotherapy such as cognitive-behavioral therapy or interpersonal therapy. Atypical antipsychotics used as add-on therapy in the treatment of depression shows some promise.
The latest 2009 CANMAT national practice guidelines for the treatment of major depressive disorder in adults[28] recommend the use of atypical antipsychotic agents such as rispiridone, olan­zapine, and aripiprazole as first-line add-on agents in the treatment of depression, while quetiapine is recommended as a second-line add-on agent owing to fewer studies.
Nonetheless, atypical antipsychotics may prove to be an effective treatment for severe or refractory depression in the elderly who fail to respond fully to other medications.
Edinburgh Postnatal Depression ScalePhysician instructions: Have the patient complete the scale by marking one answer for each question that comes closest to how she has felt in the past seven days, not just how she feels today. Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. National Institute of Mental Health treatment of Depression Collaborative Research Program. Symptom profiles of depression among general medical service users compared with specialty mental health service users. Summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders. Screening for depressive disorder in children and adolescents: validating the Center for Epidemiologic Studies Depression Scale for Children. Screening for major depression disorders in medical inpatients with the Beck Depression Inventory for Primary Care. Development and validation of a geriatric depression screening scale: a preliminary report. Many of these antiepileptic drugs (AEDs) have also proven effective in the treatment of psychiatric disorders, such as bipolar disorder, depression, and social anxiety. In general, those medications with several mechanisms of action are more effective against a broad range of seizure types. In most studies the emphasis has been on PPD using instruments that are designed to measure mostly depressive symptoms, thus the postpartum incidence of other disorders and syndromes remains unclear. In particular, depression and anxiety that start during pregnancy are likely to have different biological bases from those that arise postpartum.
A distinct range of symptoms and a different time course from the blues occurs starting on the first postpartum day.
While some episodes of depression or anxiety are triggered specifically by parturition,36 others appear for the first time during pregnancy and are resolved by childbirth.


Depression can be categorized into typical or melancholic depression and atypical depression.
Awareness of predisposing and precipitating factors can help identify patients in need of screening with tools such as the Geriatric Depression Scale. However, it is necessary first to identify and diagnose depression, which can be challenging in this population owing to communication difficulties caused by hearing or cognitive impairment, other comorbidities with physical symptoms similar to those of depression, and the stigma associated with mental illness that can limit the self-reporting of depressive symptoms. Depression in the elderly still goes undertreated and untreated, owing in part to some of these issues. Atypical antipsychotics at the lowest doses for symptom control are also recommended for the treatment of psychotic symptoms associated with depression. Besides medications, other therapies for depression that might be considered include various forms of psychotherapy and neurostimulation, with electroconvulsive therapy still being the gold standard for severe or psychotic depression.
National guidelines for seniors’ mental health: The assessment and treatment of depression. Primary care physicians, not mental health professionals, treat the majority of patients with symptoms of depression. Preventive Services Task Force (USPSTF) recently reviewed new evidence finding that patients fared best when physicians recognized the symptoms of depression and made sure that they received appropriate treatment.8 Based on this evidence, the USPSTF issued new depression screening recommendations last May, encouraging primary care physicians to routinely screen their adult patients for depression. Signs of depression that are more common in the elderly than in other populations include diminished self-care, irritability, and psychomotor retardation.
Geriatric Depression Scale–Short FormReprinted with permission from Sheikh JI, Yesavage JA. Specifically, lamotrigine was approved for maintenance therapy of adults with bipolar I disorder to delay the time to recurrence of mood episodes (ie, depression, mania, hypomania, mixed episodes). A small number of patients experience emotional lability, depression, hostility, or agitation.
As with topiramate, oligohydrosis, hyperthermia, and renal calculi have been reported.58 Typical side effects include somnolence, dizziness, ataxia, and anorexia. Injury type-specific calcium channel alpha 2 delta-1 subunit up-regulation in rat neuropathic pain models correlate with antiallodynic effects of gabapentin. What is clear is that maternal depression impacts not only the mother but also her family, especially her newborn baby.
Segre, PhD, and colleagues, share their experience with interpersonal psychotherapy (IPT) for antenatal and postpartum depression. In a subgroup of women, postpartum depression has been associated with the presence of thyroid autoantibodies during pregnancy.
A family or personal history of manic depression are known risk factors,21 and the symptoms are often, though not necessarily, of the manic-depressive type. Cortisol levels also rise greatly during pregnancy and can reach values comparable to those found in severe depression at the end of the pregnancy.44 This raises the question as to why most women do not feel depressed toward the end of their pregnancy. Melancholic depression is characterized by loss of appetite and sleep, whereas those with atypical depression tend to overeat and oversleep. However, studies that have examined levels of estrogen and progesterone in women with or without postpartum depression have generally had negative results,49,50 although Harris and colleagues51 showed that women with the blues suffered a greater drop in progesterone from the antepartum to postpartum period.
Very high estrogen and progesterone levels associated with pregnancy, and withdrawal from these high levels postpartum, were induced in women both with and without a history of postpartum depression. Although some early studies, such as one by Dalton,56 reported the benefit of progesterone in preventing postnatal depression, these were uncontrolled and have not been confirmed. In the future, clinicians should be able to understand the biological components of these disorders more fully when care is taken to differentiate the exact symptoms of each case together with the time of onset.
The growth hormone response to apomorphine at 4 days postpartum in women with a history of major depression. Thyroid peroxidase antibodies during gestation are a marker for subsequent depression postpartum. Postnatal depression and elation among mothers and their partners: prevalence and predictors.
The course of anxiety and depression through pregnancy and the postpartum in a community sample.
All measures have a statistically predetermined cutoff score at which depression symptoms are considered significant.
Early diagnosis and treatment of depression in the elderly improve quality of life and functional status, and may help prevent premature death.When using screening instruments with elderly patients, it is important to consider their level of cognitive impairment along with visual deficits. Once depression is diagnosed and treatment is initiated, repeated administration of these measures provides an excellent means of tracking response to pharmacotherapy or psychotherapy.Depression measures should be selected based on the patient population (Table 4).
As Glover and Kammerer rightfully comment, it is plausible that different vulnerabilities, hormonal-neurotransmitter processes, and environmental inputs may be involved in the various postpartum syndromes and diagnostic entities.
Gorman, PhD, comment that many risk factors have been proposed and studied, most notably lifetime history and family history of depression and other mental disorders, history of reproductive-related disorders such as premenstrual syndromes, adverse past life events (especially sexual abuse), unplanned pregnancy, depression and anxiety during pregnancy, complicated delivery, and lack of social support. The short- and long-term effects of untreated maternal depression on the baby are well demonstrated and outweigh possible adverse effects of currently used antidepressants, especially selective serotonin reuptake inhibitors (SSRIs). They emphasize the importance of a patient’s immediate environment, the infant, the partner, the immediate family, and friends on the treatment of depression.
It is important to differentiate the different types of mood disorders that occur over this time in order to understand their biological bases.


A recent study by Caspi and colleagues6 showed that it is only when one looks at a combination of life events and genetic vulnerability (in this instance, a polymorphism in the serotonin uptake transporter) that one obtains an understanding of vulnerability of depression in general. These three groups of patients are likely to have different biological bases and vulnerabilities. Further evidence for the hormonal component of perinatal disorders is given by the association of postpartum depression with other reproductive endocrine-related mood disorders, especially the premenstrual syndrome.52 However, studies in this area have been inconsistent.
The same group later showed a similar association with relapse of severe depression and anxiety.10 However, other groups have failed to replicate these promising findings,54 and more research needs to be done in this area. Vulnerability in the peripartum period likely depends on both biology and environment, with different relative contributions in different types of disorder, and in different individuals. Conversely, those with a vulnerability to atypical depression might be more prone to postnatal depression.
Outcome measures were daily symptom self-ratings and standardized subjective and objective cross-sectional mood rating scales. Identifying patients with depression can be difficult in busy primary care settings where time is limited, but certain depression screening measures may help physicians diagnose the disorder. An interview is necessary because many conditions have symptoms that are common to depression. A family history of manic depression is a strong risk factor for postpartum psychosis; there is also evidence for genetic vulnerability to a puerperal trigger. Five of the eight women with a history of postpartum depression (62.5%) and none of the eight women in the comparison group developed significant increases in depressive symptoms during the withdrawal period. In cases of severe, psychotic, or refractory depression in the elderly, electroconvulsive therapy is recommended.
Patients who score above the predetermined cut-off levels on the screening measures should be interviewed more specifically for a diagnosis of a depressive disorder and treated within the primary care physician's scope of practice or referred to a mental health subspecialist as clinically indicated. Edinburgh Postnatal Depression ScaleReprinted with permission from Cox JL, Chapman G, Murray D, Jones P.
In postpartum women, the Edinburgh Postnatal Depression Scale is the preferred measure.The use of depression screening measures in elderly patients varies with their cognitive status and clinical presentation. When the ACTH responses were analyzed separately for euthymic women and those who had the blues or depression, the blunting of ACTH was significantly more severe and long lasting in the latter group.
Although this was a small study, the authors plausibly conclude that these results provide some direct evidence in support of the involvement of these hormones in the development of postpartum depression in a subgroup of women. Targeted screening in high-risk patients such as those with chronic diseases, pain, unexplained symptoms, stressful home environments, or social isolation, and those who are postnatal or elderly may provide an alternative approach to identifying patients with depression. An evaluation is critical in ruling out conditions that may present with symptoms of depression, such as hypothyroidism and pancreatic cancer. In cognitively intact patients older than 65 years, the GDS or one-item screen are currently the preferred instrument because the psychometric data on the BDI and CES-D are mixed in this population.44In patients who have cognitive deficits, interviewer-administered instruments such as the Cornell Scale for Depression in Dementia (Figure 4)24 or the Hamilton Rating Scale for Depression45 are preferred. Use of the GDS is limited to cognitively intact or mildly impaired elderly patients and interviewer-administered instruments, such as the Cornell Scale for Depression in Dementia or the Hamilton Rating Scale, are preferable when cognitive deficits are present. However, older patients with depression may also present with unexplained somatic symptoms and may deny sadness or loss of pleasure. Self-rated depression scales and screening for major depression in the older hospitalized patient with medical illness.
It manifests as a combination of feelings of sadness, loneliness, irritability, worthlessness, hopelessness, agitation, and guilt, accompanied by an array of physical symptoms (Table 1).6 Recognizing depression in patients in a primary care setting may be particularly challenging because patients, especially men, rarely spontaneously describe emotional difficulties. These are likely to have different biological bases, possibly related to the functioning of hypothalamic-pituitary-adrenal axis of the individual. The association of depression and mortality in elderly persons: A case for multiple, independent pathways. Feasibility and effectiveness of treatments for depression in elderly medical inpatients: A systematic review.
Antidepressant pharmacotherapy in the treatment of depression in the very old: A randomized, placebo-controlled trial.
Time to response for duloxetine 60 mg once daily versus placebo in elderly patients with major depressive disorder. Methylphenidate for the treatment of depressive symptoms, including fatigue and apathy, in medically ill older adults and terminally ill adults.
Efficacy and safety of adjunctive aripiprazole in major depressive disorder in older adult patients: A pooled subpopulation analysis. Placebo-controlled study of relapse prevention with risperidone augmentation in older patients with resistant depression. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults.



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