depression—there are at least two sides to every story
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Depression—There are at least two sides to every story. Depression. It’s not only a state of mind. The symptoms of depression. Reference: Adapted from - PowerPoint PPT PresentationTRANSCRIPT
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Depression—There are at least two sides to every story.
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Depression. It’s not only a state of mind.
Reference: Adapted fromAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition,Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489.
The symptoms of depression
Emotional Symptoms Include:
Sadness
Loss of interest or pleasure
Overwhelmed
Anxiety
Diminished ability to think or concentrate, indecisiveness
Excessive or inappropriate guilt
Physical Symptoms Include:
Vague aches and pains
Headache
Sleep disturbances
Fatigue
Back pain
Significant change in appetite resulting in weight loss or gain
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Reference:1. Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.
Depression – the physical presentationIn primary care, physical symptoms are often
the chief complaint in depressed patients
N = 1146 Primary care patients with major depression
In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief compliant1
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Adapted from 1.Silverstein B. Am J Psychiatry. 1999;156(3):480-482. 2.Silverstein B. Am J Psychiatry. 2002;159(6):1051-1052.
25%
17%
58%
37%
55%
38%35%
28%
0
10
20
30
40
50
60
70
Aches/Pain(Women)
Aches/Pain (Men)
Anxiety Disorder(Women)
Anxiety Disorder (Men)
% o
f D
epre
ssed
Pat
ien
ts
National ComorbiditySurvey
NIMH EpidemiologyStudy
Aches/pain – a physical symptom of significance
Aches/Pain as common as anxiety among depressed patients
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• 76% of compliant depressed patients with lingering symptoms of depression relapsed within 10 months1*
The importance of emotional and physical symptoms
*Psychiatric inpatients and outpatients.
Reference:1. Adapted from: Paykel ES, et al. Psychol Med. 1995;25:1171-1180.
94% of depressed patients who experienced lingering symptoms had mild to moderate physical symptoms1
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Serotonin5HT and NorepinephrineNE in the brain
Limbic System
Locus Ceruleus (NE Source)
Prefrontal Cortex
Raphe Nuclei (5-HT source)
Cooper JR, Bloom FE. The Biochemical Basis of Neuropharmacology. 1996.
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There are at least two sides to the neurotransmitter story
Sex
Appetite
Aggression
Concentration
Interest
Motivation
Depressed Mood
Anxiety
Irritability
Thought process
References:
1. Adapted from: Stahl SM. In: Essential Psychopharmacology: Neuroscientific Basis and Practical Applications: 2nd ed. Cambridge University Press 2000.
2. Blier P, et al. J Psychiatry Neurosci. 2001;26(1):37-43.
3. Doraiswamy PM. J Clin Psychiatry. 2001;62(suppl 12):30-35.
4. Verma S, et al. Int Rev Psychiatry. 2000;12:103-114.
Norepinephrine (NE)
• Both serotonin and norepinephrine mediate a broad spectrum of depressive symptoms
Serotonin (5-HT)
Vague Aches and pain
Functional domains of Serotonin and Norepinephrine1-4
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The neurotransmitter pathway story
Adapted from References:
1. Stahl SM. J. Clin Psych. 2002;63:203-220.
2. Verma S, et al. Int Rev Psychiatry. 2000;12:103-114.
3. Blier P, et al. J Psychiatry Neurosci. 2001;26(1):37-43.
• Dysregulation of Serotonin (5HT) and Norepinephrine (NE) in the brain are strongly associated with depression
• Dysregulation of 5HT and NE in the spinal cord may explain an increased pain perception among depressed patients1-3
• Imbalances of 5HT and NE may explain the presence of both emotional and physical symptoms of depression.
It’s not all in your head
Descending Pathway
Ascending Pathway
AscendingPathway
DescendingPathway
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Depression: Current treatment outcomes1
• Up to 70% of depressed patients respond ( 50% decrease in HAM-D score) to treatment but fail to achieve remission from their emotional and physical symptoms1*
• Approximately 30% of depressed patients achieve remission ( 7 score on the HAM-D) with treatment1*
References:1. O’Reardon JR, et al. Psychiatr Ann. 1998;28:633-640.
* Antidepressant clinical drug trials.
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Response and Remission defined
Hamilton Depression Rating Scale (HAM-D): 17 Items, Total Score 0 - 52
15
7
Response 50% reduction from baseline HAM-D
score
Remission: HAM-D Score 7
Depression (Major Depressive Disorder)
References:1. Frank E. Conceptualization and rationale for consensus definition terms in MDD, Arch Gen Psych. 1991; 48:851-855.
HAM-D17 Scores
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Study in chronic depressed patients
*p.05 vs nonresponse. **p.05 vs response.
Miller IW, et al. J Clin Psychiatry. 1998;59(11):608-619.
Normal(n=482)
Remission (n=202)
Response(n=122)
Nonresponse(n=299)
Soci
al A
djus
tmen
t Sca
le-S
R
(Mea
n ±
SD)
***
*
1
2
3
5
Treatment outcome:Effect on work & social functioning
Higher Score indicates greater
impairment
Remitted patients virtually equaled healthy controls on functioning levels at endpoint of 12-week treatment trial
(Responders & non-responders did not)
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Many depressed patients are still depressed.
References:
1. Nierenberg AA, et al. J Clin Psychiatry. 1999:60(suppl 22):7-11.
2. O’Reardon JR, et al. Psychiatr Ann. 1998;28:633-640.
3. Lynch ME. J Psychiatry Neurosci. 2001;26(1):30-36.
Depressed patients continue to have needs that are not being fully addressed1
• Depressed patients present with emotional and physical symptoms.
• Approximately 30% of depressed patients achieve remission in clinical trials2*
• Up to 70% of patients who respond fail to remit2*
• Incomplete relief from symptoms may increase the risk of relapse2,3
• Lingering emotional and physical symptoms may jeopardize achieving remission.
*In antidepressant clinical drug trials.