Chapter Depression Barbour, Hoffman, and Blumenthal C H A P T E R

Definition A term often used to refer to varying levels of psychological distress, ranging from dysphoric mood state to the diagnosis of a clinical disorder such as major depressive disorder (MDD).

Summary of DSM-IV Diagnostic Criteria for Major Depressive Episode Five (or more) of the following symptoms are present during the same 2 wk period and represent a change from previous functioning (note that at least one of the symptoms must be either number 1 or number 2). 1.Depressed mood most of the day, nearly every day 2.Diminished interest or pleasure in all or most activities 3.Significant change in weight or appetite (continued)

Summary of DSM-IV Diagnostic Criteria for Major Depressive Episode (continued) 4.Insomnia or hypersomnia 5.Psychomotor agitation or retardation 6.Fatigue or loss of energy 7.Feelings of worthlessness or guilt 8.Diminished ability to think or concentrate 9.Recurrent thoughts of death or suicide Note. The symptoms cause clinically significant distress or impairment, are not caused by the effects of a substance or general medical condition, and are not better accounted for by bereavement or another psychiatric disorder.

Scope ~17% of adults suffer or have suffered from MDD sometime during their lifetime 80% of those meeting criteria for MDD classified as having moderate to severe episodes Women > men; Latinos and African Americans generally < than Caucasians Economic burden of depression exceeds $44 billion

Pathophysiology of Depression Interaction between genetics and environment; both neurochemical (deficiencies of norepinephrine, serotonin, dopamine) and behavioral factors involved Associated with autonomic nervous system dysregulation, increased inflammation, platelet reactivity, and endothelial dysfunction Negative evaluations of self (self-efficacy, self-worth)

Clinical Considerations Gold standard for the diagnosis of depression is structured interview administered by mental health professional. Typical screening tools include Beck Depression inventory, Hospital Anxiety and Depression Scale (continued)

Clinical Considerations (continued) Signs and symptoms include hopelessness, suicidal ideations, poor self-worth, fatigue, loss of interest, indecisiveness, and difficulty concentrating. Depression may be associated with family conflict and unemployment, lower exercise tolerance compared to matched controls, poor attendance or compliance with prescribed therapies such as exercise.

Clinical Considerations: Treatment Usually treated by primary care practitioner (vs. mental health professional) Antidepressant medications –Buproprion—does not share a chemical structure with other types of antidepressant medications and as a result is considered a miscellaneous or “other” antidepressant medication –SSRI = selective serotonin reuptake inhibitors –SNRI = serotonin and norepinephrine reuptake inhibitors –NaSSA = noradrenergic and specific serotonergic antidepressants

Clinical Considerations: Treatment (continued) Psychotherapy –Cognitive–behavioral therapy Exercise training –Impact on depression equivalent to that of antidepressive medications –40 to 60 min, 60% to 75% of heart rate reserve, 5 d/wk –Adherence a challenge in patients with depression; counter by: Establishing rapport Helping to identify benefits Making enjoyable Setting realistic goals with reward system in place

Conclusion Screening for depressive symptoms that may interfere with exercise and subsequent referral for treatment are essential. The clinical exercise physiologist should recognize that the depressed person who exercises is at risk for nonadherence, that depression is common in patients with CHD and other chronic diseases, and that depressive symptoms may interfere with the enjoyment of exercise and motivation to fully engage in the rehabilitation process.

Conclusion (continued) Several treatments have shown success in the treatment of depression, including antidepressant medication, cognitive– behavioral therapy, and exercise training. Patients who exhibit significant depressive symptoms should be approached in an empathetic manner and encouraged to seek treatment to improve quality of life and gain maximal benefit from exercise.