Presentation on theme: "Ask the Expert: Depression Presenter: Kenneth J. Herrmann, MD NAMI Conference Spring 2014."— Presentation transcript:
Ask the Expert: Depression Presenter: Kenneth J. Herrmann, MD NAMI Conference Spring 2014
Medical School at Chicago Medical School Internship, residency in general psychiatry, fellowship in child and adolescent psychiatry at the University of Iowa Formerly, Medical Director of Youth Services at the Mental Health Center of Dane Co. Psychiatric Consultant, Psychiatric Services SC, Past Vice-President, Board of Directors NAMI WI Principal, My World Defense, A Healthcare Security Company, Kenneth J Herrmann M.D.
Irritable/Depressed mood, diminished pleasure/interest Weight changes of greater than 5% in one month Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy, poor concentration Feelings of worthlessness, suicidal thoughts, guilt Diagnosis of Major Depressive Disorder
Genetic factors Personality and environmental factors Biochemical abnormalities Etiology of Depression
Depression -Duration average of 7 1/2 months -44% in remission within 6 months of Dx -92% recovered by 1 ½ years -72% recurrence within five years Prognosis - Adolescence
Depression: -2% of children in general population -7% depression in children admitted to Hospital -40% children in ped neuro clinics with headaches=depression -4.7% ages (3.3% dysthymia) (as age increases female rates increase) -one in five adolescents by age 20 -Lifetime: Males 12% Females 25% EPIDEMIOLOGY
Age at onset is decreasing Incidence is increasing Trends for Affective Disorders
Substance Use Prematurity Family History Head Injury Risk Factors For Mood Disorders
Hard to recruit for certain disorders FDA requirements for drug approval Funding Exclusion criteria Dropout rates Liability Time from idea to publication Limitations of Current Research
Moderate to severe depression Fluoxetine alone or in combo with CBT 13 academic and community sites in the US yrs old Combined > mono 42 week total study time Study start 7/98, completed 3/04 Arch. Gen. Psychiatry 10/07 The Treatment for Adolescents with Depression Study (TADS)
Thinking Outside the Box?
? Adequate information ? Diagnosis Increase in antidep. use / decrease in suicides over 10 years prior to warning FDA warnings and the Antidepressants
CONCLUSIONS: In both the United States and the Netherlands, SSRI prescriptions for children and adolescents decreased after U.S. and European regulatory agencies issued warnings about a possible suicide risk with antidepressant use in pediatric patients, and these decreases were associated with increases in suicide rates in children and adolescents. Gibbons etal. Am J. Psychiatry 9/07
Diagnostic Accuracy is Most Important
Elevated, expansive or irritable mood Inflated self-esteem or grandiosity Decreased need for sleep More talkative (distractible) Flight of ideas or racing thoughts Increase in activity Foolish indulgencies Mania/Bipolar Affective Disorder (BPAD)
Grandiosity Inappropriate sexual interest Psychotic symptoms “ Ultrarapid ” cycling Characteristics of BPAD in Children
… you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? … you were so irritable that you shouted at people or started fights or arguments? … you felt much more self-confident than usual? … you got much less sleep than usual and found you didn’t really miss it? … you were much more talkative or spoke much faster than usual? … thoughts raced through your head or you couldn’t slow your mind down? Mood Disorder Questionnaire Hirschfeld et al. Am J Psychiatry. 2000;157: Has there ever been a period of time when you were not your usual self and…
… you were so easily distracted by things around you that you had trouble concentrating or staying on track? … you had much more energy than usual? … you were much more active or did many more things than usual? …you were much more social or outgoing than usual; for example, you telephoned friends in the middle of the night? … you were much more interested in sex than usual? … you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? … spending money got you or your family into trouble? Mood Disorder Questionnaire (cont ’ d) Hirschfeld et al. Am J Psychiatry. 2000;157:
Depressive symptoms were predominant Over the long term, patients with bipolar I disorder spent nearly half of their time symptomatically ill Depression accounted for 31.9% of the time Patients experienced manic symptoms 9.3% of the time Depression (but not mania) predicted greater future illness burden Judd et al. Arch Gen Psychiatry. 2002;59: Long-term Frequency of Depressive Symptoms (Percent of Follow-up Weeks) Patients with bipolar I disorder experienced mood symptoms nearly half of the time during a 12.8-year follow-up period.
Age of Onset (Pooled Data N=1,304) Goodwin F, Jamison K. Manic Depression. New York: Oxford University Press; 1990.
Acute onset Hypersomnic retarded depression Psychosis Postpartum onset Family history Antidepressant Hypersomnia Predictors of BPAD Outcome
Wgt neutral?, EPS, Nonsedating, Agitation FDA approved ABILIFY® (aripiprazole) for the acute treatment of manic and mixed episodes, maintenance treatment of manic or mixed episodes, and as add-on treatment to lithium or valproate, associated with Bipolar I Disorder, with or without psychotic features, and schizophrenia in pediatric patients (10 to 17 years old). Refractoy DepressionABILIFY Aripiprazole (Abilify)
Treatment: Risperidone (Risperdal) Positives: No blood tests Once a day dosing Fast Shotgun FDA approved Risperdal (risperidone) for the treatment of schizophrenia in adolescents, ages 13 to 17, and for the short- term treatment of manic or mixed episodes of bipolar I disorder in children and adolescents ages 10 to 17. Negatives: Prolactin Some reports of mania induction Weight gain Sedation NMS Tardive dyskinesia Diabetes risk
Treatment: Olanzapine (Zyprexa) Positives: No blood tests Once a day dosing Data FDA indication Fast Shotgun Negatives: Sedation Weight gain Diabetes risk
Treatment: Lithium Positives: Low suicide rates FDA approved 12yrs and older Long history of use Once a day dosing Cheap Negatives: Narrow therapeutic window Fluid balance issues Monitoring (thyroid & kidney) Acne Weight
Lurasidone (Latuda): (Bipolar Depression)Once a day, with food, sedation and EPS Asenapine (Saphris): Once a day, disolves in mouth- some find unpleasant taste Iloperidone (Fanapt) Twice a day The 3 Newest
SADS Hospice family members Buproprion For Prevention of Depressive sx ’ s
Neurotrophic Effects of Mood Stabilizers? MRI studies “ …revealed that chronic lithium significantly increases total grey mattervolume in the human brain of patients with manic- depressive illness. Neuroprotective? “ …lithium and valproate have recently been demonstrated to robustly increase the expression of the cytoprotective protein bcl-2 in the central nervous system. ” Husseini et. al. The Good News
“Your doctor may use cytochrome P450 tests (CYP450 tests) to help determine how your body processes (metabolizes) a drug. Our bodies contain numerous P450 enzymes to process medications. Because of inherited (genetic) traits which cause variations in these enzymes, medications affect each person differently.” From a Mouth Swab
Earlier Identification and Aggressive Txmnt Increase focus on primary and especially secondary Prevention Neurotransmitter and enzyme specific treatment. More delineation of “ Normal ” behavior and it ’ s relationship to our genes. More Exploration of Combined Therapy Remission not just response Future Trends Summary