Depressive Disorders and Substance Use Disorders

Major Depressive Disorder  Major depression is a treatable disorder  Major depression has a significant morbidity (prevalence) and a notable mortality rate (leading to death)  Major depression is one of a number of different mood disorders

Major Depressive Disorder  Presence of one (Single Episode) or more (Recurrent) Major Depressive Episodes  Not better accounted for by a Schizoaffective or other type of disorder  Not accompanied by any episodes of mania

Depressive Episode A. Five or more of the following are present during the same 2- week period, and represent a change from previous functioning, and at least one of the symptoms is either (1) depressed mood, or (2) loss of interest...

Depressive Episode 1) Depressed mood most of the day, every day 2) Loss of interest or pleasure in most all activities, every day 3) Significant weight loss w/o dieting 4) Insomnia / hypersomnia every day 5) Psychomotor agitation / retardation every day 6) Fatigue or energy loss every day 7) Worthlessness or inappropriate guilt feelings nearly every day 8) Decreased ability to think, concentrate or make decisions nearly every day 9) Recurrent thoughts of death, or suicidal ideation, with or without plan &/or attempt

Depressive Episode B. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Depressive Episode C. Symptoms are NOT due to the effects of a substance (e.g., drug of abuse, or medication) or a general medical condition (e.g., hyperthyroidism)

Depressive Episode D. Symptoms are not better accounted for by Bereavement (i.e. lasting longer than 2 months after a significant loss, or characterized by severe degree of functional impairment, preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation)

Prevalence  The National Comorbidity Survey found: For any mood disorder Life time prevalence was 19.3% Annual prevalence was 11.3% For Major Depressive Episode Life time prevalence was 17.1% Annual prevalence was 10.3% Female to male ratio is 2:1

A Spectrum of Depression  Some of the types of depressive disorders include Dysthymic Disorder Major Depressive Disorder “clinical depression” Post Partum Depression Seasonal Affective Disorder Mood disorder secondary to a medical condition Substance induced mood disorder Other mood disorders can include depressive episodes, such as Bipolar disorder

Gender differences  The lifetime prevalence rate of major depression is estimated at between 5 to 12% for men between 10 to 25% for women

Age  Depression can happen at any age  Teenagers can have depression -adolescent rate is between 3 and 8% -teen depression is estimated to be 6x more likely when a parent also has depression -signs/symptoms can be masked “irritable moodiness” -suicide is the 3 rd leading cause of death for year olds

Co-Occurring Medical Conditions  Nearly 70% of all anti depressant medication prescriptions are written by primary care doctors  Certain medical disorders are associated with higher-than-expected rates of depression Stroke Neurodegenerative disorders HIV/AIDS Endocrine disorders Diabetes

What isn’t depression?  “The blues” – temporary  Normal grief – situational  Depression is an illness, while “the blues” are normal reactions to life situations.  Symptoms of depression include multiple moods, thoughts, and bodily functions whereas the blues is composed of a single state of being in a low mood  Depression may persist for months, years, decades

Dysthymic Disorder  Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years, but without a major depressive episode occurring.

Dysthymic Disorder  Dysthymic depression has 2 or more of the following: Poor appetite, or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness

Other forms of depression  Postpartum Depression A condition which describes a range of physical and emotional changes a woman may have after having a baby. Most partum depression can range from a mild degree to severe with psychotic features (postpartum psychosis). This is not the “baby blues”. -happens from several days to several months post childbirth -higher level of intensity -interferes with functioning

Postpartum Depression Symptoms include:  Restlessness  Irritability  Feeling sad  Crying a lot  Lack of energy  Headaches  Chest pains, heart palpitations  Difficulty sleeping and/or eating  Trouble concentrating  Sense of being overly worried about baby  Not having any interest in the child  Feelings of worthlessness, guilt  Fear of harming self or child

Seasonal Affective Disorder It is noticed that animals react to the changing seasons in mood & behavior and human beings are no exception. Most people have a tendency to eat and sleep a little more in the winter and dislike the dark mornings and short days. For some, it seems to have a more intense effect in disrupting their lives and causing significant distress. Symptoms include: Change in appetite, weight gain, “heavy feeling” in arms/legs, drop in energy level, fatigue, oversleeping, difficulty concentrating, irritability, increase sensitivity to others, avoidance of social situations.  Estimated 10-20% may experience some mild form of SAD, more common in women  Usually starts after age 20  More common in northern geographic regions, September – April There’s an association with lack of bright light- bright light makes a difference to the brain chemistry although they are not sure by what means the sufferers are affected. Treatment includes natural light, light box/full spectrum light, behavioral therapy, medication when necessary.

What about Depression & Substance Use?  For discussion: Why would someone with depression use substances? What is the risk of using substances when there is a co-occurring depressive disorder?

Dual Diagnosis Issues  Certain intoxication syndromes (usually with depressant substances) &/or withdrawal syndromes (usually from stimulants) can mimic some of the symptoms of a depressive episode, thus making accurate diagnosis and effective treatment more complicated.  Exs. Sedative intoxication, Cocaine withdrawal

Sedative Intoxication Inappropriate sexual or aggressive behavior Slurred speech Stupor Impaired attention or memory Mood lability Impaired judgment Psychomotor retardation or agitation Impaired social, occupational, or other functioning

Cocaine Withdrawal Depressed mood Fatigue Vivid, unpleasant dreams Insomnia or hypersomnia Increased appetite Psychomotor retardation or agitation Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Sedative Intoxication Inappropriate sexual or aggressive behavior Slurred speech Stupor Impaired attention or memory Mood lability Impaired judgment Psychomotor retardation or agitation Impaired social, occupational, or other functioning

Cocaine Withdrawal Depressed mood Fatigue Vivid, unpleasant dreams Insomnia or hypersomnia Increased appetite Psychomotor retardation or agitation Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Why does depression happen?  Emerging data supports that stress genetic predisposition differences in brain chemistry & brain structures life experiences Interact to cause depression.

Genetic Factors First degree relatives of depressed individuals have a higher rate of depression.

Brain Structures  Post-mortem receptor studies in depressed suicide victims show differences in the hippocampus, hypothalamus, and prefrontal cortex.  Neruo imaging studies shows impaired regulation of serotonergic activity.

Life Experiences  Abnormal stress at critical development periods may have long lasting effects on the CNS development. Emerging evidence indicates that individuals with depression are more likely (than controls) to have a history of childhood abuse, deprivation, or abandonment

Suicide Awareness  The vast majority of people who SEEK treatment have success in alleviating symptoms.  Not everyone who has depression becomes suicidal, but over 90% of those who die of suicide have a diagnosable mental illness Warning signs include:  Talking about suicide.  Statements about hopelessness, helplessness, or worthlessness.  Preoccupation with death.  Suddenly happier, calmer.  Loss of interest in things one cares about.  Visiting or calling people one cares about.  Making arrangements; setting one's affairs in order.  Giving things away.

Seek Help!  Community Crisis Response Team (CCRT) (24/7)  Psychiatric Emergency Services (24/7)  CSTS or other mental health providers  Hotlines SUI-CIDE TALK  For every 25 attempts there is 1 death. Take attempts seriously. Seek help!

Treatment options  “Multi modal” Anti depressant medication Psychotherapy Behavior/lifestyle: exercise, nutrition, sleep light therapy ECT

Principles of Dual Recovery  Treatment of both mental illness and substance abuse at the same time  Individualized dual recovery plan  Collaboration and coordination  Keeping hope alive

Principles of Dual Recovery  Medication adherence  Dual diagnosis &/or other treatment groups  Self-help groups (DRA, DBSA, AA, NA), other support networks  Family support and problem solving  Individual therapy  Motivational strategies

Principles of Dual Recovery  Managing stressors, triggers, relapse risk factors  Skill-building in areas of need  Increased overall structure and lifestyle balance (including proper diet, exercise, sleep habits)

Any Questions or comments?

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