Case 3: Depressed Diane

Group 3 Members:
Ensy Caroline Farhath Jabien Felicia Lim Shang Fei Khin Nyein Kyi Ng Miow Ling Thushara Ansari

DIANES SITUATIONS
21 year old University student
Living alone for last 6 months Struggle to make friends and homesick

Poor attendance, negative view of the course

Less groomed, no eye contact and tired

LEARNING OBJECTIVES

Review symptoms of depression Consider drug treatments for depressive disorders & their mechanism of action and adverse effects Discuss alternative to pharmacological treatment

Review the underlying pathophysiology of depression

WHAT IS DEPRESSION?

State of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical wellbeing Types Causes

Exogenous/ Major Depression (75%)

Hereditary

Endogenous Depression (25%)

Environment

SYMPTOMS OF DEPRESSION
Emotional
Low self-esteem, miserable, pessimism, feelings of guilt, loss of interest/ pleasure/ motivation, anti-social, agitated, anxiety, suicidal

Physical
Fatigue, weight loss/gain

Biological
insomnia, loss of appetite, retardation of thought and action, hallucination/delusions (if severe)

DIANES SYMPTOMS
Lack of motivation Fatigue Anxiety/ Miserable Pessimistic
Poor attendance and punctuality

Sounds lethargic Lacks of grooming

Avoids eye contact Struggled to make friends Home sick

Negative view towards course, abilities, and future

THEORIES OF BIOCHEMICAL ABNORMALITY

THE MONOAMINE THEORY (BIOGENIC AMINE THEORY)

proposed by Schildkraut in 1960s Low level of biogenic amine function leads to depressive symptoms Antidepressants play a role by elevating serotonin / NA level by:
Inhibiting the reuptake mechanism Inhibiting enzymes that breakdown Enhance release of neurotransmitters from nerve terminals

BIOGENIC AMINE THEORY (SEROTONIN HYPOTHESIS)

Born from 1st theory in 1980s Decreased serotonin level generates depressive symptoms

Secondary down-regulation of NA & dopamine influence

Explains why certain symptoms are tied with specific neurotransmitters

NA lack of alertness and interest DA lack of attention and motivation

Serotonin anxiety obsession compulsion

WHY HYPOTHESIS REMAINS

Neurotransmitters level low, drugs restore

Effect is quicker than time taken by antidepressants to be effective

Adaptive responses in brain occurs Reduced receptor function Clinical benefit due to such response, not due to monoamine influence

WHY HYPOTHESIS REMAINS

Some antidepressants do not enhance neurotransmitters activity Eg: Tianeptine enhance serotonin re uptake Some drugs lower serotonin & NA influence without creating depression

Currently, biogenic amines are involved in therapeutic response to drugs Unclear what this tells about nature of depression

FORMAL DIAGNOSIS
The International Criteria for Disease (ICD-10) of WHO & Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

Medical history & current medication

Depression test (e.g. Becks Depression Inventory Test)

Laboratory Tests: blood test, basic electrolyte serum test, etc

TREATMENT: PSYCHOTHERAPY
Interpersonal Therapy
Focus on behaviours and interactions between the patients with family and friends. Improve communication skills and increase selfesteem.

Psychodinamic Therapy

Causes are assumed to be unresolved conflicts, often stemming from childhood

understand and cope better with these feelings by talking about the experiences

TREATMENT: PSYCHOTHERAPY
Focus on how thinking affects the way a person feels and acts feel better, remain calm, even when the situation stays the same Most suitable for Diane

Cognitive Behavioural Therapy

DIANES CONDITION
Insomnia Loss of appetite & weight Score moderately to severely depressed on Beck Depression Inventory test

GPs advise
Increase exercise level of

Paroxetine (20mg/d)

Problems

GENERAL MECHANISM OF ANTIDEPRESSANT DRUGS

Increase availability of target monoamine neurotransmitter by:

a) inhibiting neurotransmitters removal by uptake b) inhibiting breakdown by enzymes

Alternative Mechanism:

Reducing monoamine breakdown by MAOIs

Types:
SSRIs TCAs SNRIs NARIs NASSAs MAOIs

MECHANISM OF ACTION OF PAROXETINE

Belongs to SSRI (Selective Serotonin Reuptake Inhibitor)

Potently & selectively inhibit neuronal serotonin reuptake through antagonism of the serotonin transporter in membrane
Location of the reuptake of 5-HT and/or NA (weak inhibition)

monoaminergic nerve terminal.

SIDE EFFECTS OF PAROXETINE

Dianes side effects
Typical headaches, nausea, diarrhoea, weight loss, complete loss of appetite, insomnia

Other side effects

Agitation, anorgasmia, inhibit metabolism of other drugs, tremor, muscle weakness/spasm, seizures

ANOTHER APPOINTMENT WITH THE GP

*Change medication to Amitriptyline

TRY EXERCISE MORE ???

Gain confidence Reduce stress Active and get more interaction Release endorphine

MECHANISM OF ACTION OF AMITRIPTYLINE

Inhibits the reuptake of NA

Inhibits the membrane pump mechanism responsible for uptake of NA and 5-HT in adrenergic and serotonergic neurons.
Prolong neuronal activity by increasing neurotransmitters
Class of antidepressants: Tricyclic Antidepressants (TCAs) Non-selective receptor blocking action
(Due to the tricyclic chemical structure)

SIDE EFFECTS OF AMITRIPTYLINE

Sedation (H1 block) Postural hypotension (-adrenoceptor block) Constipation (Muscarinic block)

Blurred vision

Dry mouth

Urinary retention

Epilepsy

Weight gain

Skin rash

Nausea

Vomiting

COMMON TO TRY MORE THAN ONE MEDICATION?

*Yes, if there is low or no response to the amount of drug given

Increase dosage

Change anti-depression drugs with consideration

Takes time to prescribe right dosage & type of antidepressant

COMMON TO TRY MORE THAN ONE MEDICATION?

. Combination of antidepressants (Eg. Tricyclic along with MAOI or lithium or SSRI with mianserin or lithium)

Combine medicine with psychotherapy

.

Electroconvulsive Therapy (ECT) .

CONCLUSION
What defines a best suited treatment?

Efficacy

Adverse side effects

Psychoterapy

Anti-Depressant Drug

REFERENCES

A.C.Shaw, 2001.Counselling and Psychotherapy today. Singapore: Mcgraw hill. American Psychiatric Association.Diagnostic and statistical manual of mental disorders, 2010. 4th edition.USA . D.Healy,1997. Psychiatric drugs explained.4th edition.UK: Elsevier church hill livingstone. Boarder,M.,Newby,D.,Navti,P., 2010. Pharmacology for pharmacy and the health sciences. USA: Oxford University Press Inc Seligman,L. Richenberg,L.W., 2010.Theories of Counselling and Psychotherapy. Internation edition. USA: Pearson Education,Inc WebMD,2011,WebMD. Better information.Better health. [online] available from: http://www.webmd.com/depression/tc/depression-topic-overview [accessed on]: 27th January 12.