841 resultados para Major Depressive Disorder
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Background: Recent work has demonstrated that the lifetime suicide risk for patients with DSM IV Major Depression cannot mathematically approximate the accepted figure of 15%. Gender and age significantly affect both the prevalence of major depression and suicide risk, Methods: Gender and age stratified calculations were made on the entire population of the USA in 1994 using a mathematical algorithm. Sex specific corrections for under-reporting were incorporated into the design. Results: The lifetime suicide risks for men and women were 7% and 1%, respectively. The combined risk was 3.4%. The male:female ratio for suicide risk in major depression was 10:1 for youths under 25, and 5.6:1 for adults. Conclusions: Suicide in major depression is predominantly a male problem, although complacency towards female sufferers is to be avoided. Diagnosis of major depression is of limited help in predicting suicide risk compared to case specific factors. The male experience of depression that leads to suicide is often not identified as a legitimate medical complaint by either sufferers or professionals. Increasing help-accessing by males is a priority. Clinical implications: Patients with a history of hospitalisation; comorbidity, especially for substance abuse; and who are male, require greater vigilance for suicide risk. It may be that for males che threshold for diagnosing and treating major depression needs to be lowered. Limitations: This research is based on a mathematical algorithm to approximate a life-long longitudinal study that identifies community cases of depression. Our findings therefore rely on the validity of the statistics used. Extrapolation is limited to populations with an actual suicide rate of 17/100,000 or less and a lifetime prevalence of major depression of 17% or more. (C) 1999 Elsevier Science B.V. All rights reserved.
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We compared the age-at-first-registration for patients with schizophrenia and affective psychosis in a statewide mental health register. After excluding those receiving (1) a diagnosis of both schizophrenia (ICD-9 295.x) and affective psychosis (ICD-9 296.x), or (2) a diagnosis of ICD-9 296.1 (which can cover major depressive episode), we adjusted the distributions for the age structure of the background general population. We found that all distributions showed a wide age range of onset, with a similar male modal age group of 20-24 for schizophrenia and 25-29 for affective psychosis. The female modal age group was 50-54 for both diagnoses. Although more individuals were diagnosed with schizophrenia (males = 2,434, females = 1,609) than with affective psychosis (males = 670, females = 913), the shape of the two distributions was similar. This finding suggests that factors influencing age-at-first-registration for schizophrenia and affective psychosis may be similar, especially for females.
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The amygdala participates in the detection and control of affective states, and has been proposed to be a site of dysfunction in affective disorders. To assess amygdala processing in individuals with unipolar depression, we applied a functional MRI (fMRI) paradigm previously shown to be sensitive to amygdala function. Fourteen individuals with untreated DSM-IV major depression and 15 healthy subjects were studied using fMRI with a standardized emotion face recognition task. Voxel-level data sets were subjected to a multiple-regression analysis, and functionally defined regions of interest (ROI), including bilateral amygdala, were analyzed with MANOVA. Pearson correlation coefficients between amygdala activation and HAM-D score also were performed. While both depressed and healthy groups showed increased amygdala activity when viewing emotive faces compared to geometric shapes, patients with unipolar depression showed relatively more activity than healthy subjects, particularly on the left. Positive Pearson correlations between amygdala activation and HAM-D score were found for both left and right ROIs in the patient group. This study provides in vivo imaging evidence to support the hypothesis of abnormal amygdala functioning in depressed individuals. (C) 2009 Elsevier Ireland Ltd. All rights reserved.
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RESUMO:A depressão clínica é uma patologia do humor, dimensional e de natureza crónica, evoluindo por episódios heterogéneos remitentes e recorrentes, de gravidade variável, correspondendo a categorias nosológicas porventura artificiais mas clinicamente úteis, de elevada prevalência e responsável por morbilidade importante e custos sociais crescentes, calculando-se que em 2020 os episódios de depressão major constituirão, em todo o mundo, a segunda causa de anos de vida com saúde perdidos. Como desejável, na maioria dos países os cuidados de saúde primários são a porta de entrada para o acesso à recepção de cuidados de saúde. Cerca de 50% de todas as pessoas sofrendo de depressão acedem aos cuidados de saúde primários mas apenas uma pequena proporção é correctamente diagnosticada e tratada pelos médicos prestadores de cuidados primários apesar dos tratamentos disponíveis serem muito efectivos e de fácil aplicabilidade. A existência de dificuldades e barreiras a vários níveis – doença, doentes, médicos, organizações de saúde, cultura e sociedade – contribuem para esta generalizada ineficiência de que resulta uma manutenção do peso da depressão que não tem sido possível reduzir através das estratégias tradicionais de organização de serviços. A equipa comunitária de saúde mental e a psiquiatria de ligação são duas estratégias de intervenção com desenvolvimento conceptual e organizacional respectivamente na Psiquiatria Social e na Psicossomática. A primeira tem demonstrado sucesso na abordagem clínica das doenças mentais graves na comunidade e a segunda na abordagem das patologias não psicóticas no hospital geral. Todavia, a efectividade destas estratégias não se tem revelado transferível para o tratamento das perturbações depressivas e outras patologias mentais comuns nos cuidados de saúde primários. Novos modelos de ligação e de trabalho em equipa multidisciplinar têm sido demonstrados como mais eficazes e custo-efectivos na redução do peso da depressão, ao nível da prestação dos cuidados de saúde primários, quando são atinentes com os seguintes princípios estratégicos e organizacionais: detecção sistemática e abordagem da depressão segundo o modelo médico, gestão integrada de doença crónica incluindo a continuidade de cuidados mediante colaboração e partilha de responsabilidades intersectorial, e a aposta na melhoria contínua da qualidade. Em Portugal, não existem dados fiáveis sobre a frequência da depressão, seu reconhecimento e a adequação do tratamento ao nível dos cuidados de saúde primários nem se encontra validada uma metodologia de diagnóstico simples e fiável passível de implementação generalizada. Foi realizado um estudo descritivo transversal com os objectivos de estabelecer a prevalência pontual de depressão entre os utentes dos cuidados de saúde primários e as taxas de reconhecimento e tratamento pelos médicos de família e testar metodologias de despiste, com base num questionário de preenchimento rápido – o WHO-5 – associado a uma breve entrevista estruturada – o IED. Foram seleccionados aleatoriamente 31 médicos de família e avaliados 544 utentes consecutivos, dos 16 aos 90 anos, em quatro regiões de saúde e oito centros de saúde dotados com 219 clínicos gerais. Os doentes foram entrevistados por psiquiatras, utilizando um método padronizado, o SCAN, para diagnóstico de perturbação depressiva segundo os critérios da 10ª edição da Classificação Internacional de Doenças. Apurou-se que 24.8% dos utentes apresentava depressão. No melhor dos cenários, menos de metade destes doentes, 43%, foi correctamente identificada como deprimida pelo seu médico de família e menos de 13% dos doentes com depressão estavam bem medicados com antidepressivo em dose adequada. A aplicação seriada dos dois instrumentos não revelou dificuldades tendo permitido a identificação de pelo menos 8 em cada 10 doentes deprimidos e a exclusão de 9 em cada 10 doentes não deprimidos. Confirma-se a elevada prevalência da patologia depressiva ao nível dos cuidados primários em Portugal e a necessidade de melhorar a capacidade diagnóstica e terapêutica dos médicos de família. A intervenção de despiste, que foi validada, parece adequada para ser aplicada de modo sistemático em Centros de Saúde que disponham de recursos técnicos e organizacionais para o tratamento efectivo dos doentes com depressão. A obtenção da linha de base de indicadores de prevalência, reconhecimento e tratamento das perturbações depressivas nos cuidados de saúde primários, bem como a validação de instrumentos de uso clínico, viabiliza a capacitação do sistema para a produção de uma campanha nacional de educação de grande amplitude como a proposta no Plano Nacional de Saúde 2004-2010.------- ABSTRACT: Clinical depression is a dimensional and chronic affective disorder, evolving through remitting and recurring heterogeneous episodes with variable severity corresponding to clinically useful artificial diagnostic categories, highly prevalent and producing vast morbidity and growing social costs, being estimated that in 2020 unipolar major depression will be the second cause of healthy life years lost all over the world. In most countries, primary care are the entry point for access to health care. About 50% of all individuals suffering from depression within the community reach primary health care but a smaller proportion is correctly diagnosed and treated by primary care physicians though available treatments are effective and easily manageable. Barriers at various levels – pertaining to the illness itself, to patients, doctors, health care organizations, culture and society – contribute to the inefficiency of depression management and pervasiveness of depression burden, which has not been possible to reduce through classical service strategies. Community mental health teams and consultation-liaison psychiatry, two conceptual and organizational intervention strategies originating respectively within social psychiatry and psychosomatics, have succeeded in treating severe mental illness in community and managing non-psychotic disorders in the general hospital. However, these strategies effectiveness has not been replicated and transferable for the primary health care setting treatment of depressive disorders and other common mental pathology. New modified liaison and multidisciplinary team work models have been shown as more efficacious and cost-effective reducing depression burden at the primary care level namely when in agreement with principles such as: systematic detection of depression and approach accordingly to the medical model, chronic llness comprehensive management including continuity of care through collaboration and shared responsibilities between primary and specialized care, and continuous quality improvement. There are no well-founded data available in Portugal for depression prevalence, recognition and treatment adequacy in the primary care setting neither is validated a simple, teachable and implementable recognition and diagnostic methodology for primary care. With these objectives in mind, a cross-sectional descriptive study was performed involving 544 consecutive patients, aged 16-90 years, recruited from the ambulatory of 31 family doctors randomized within the 219 physicians working in eight health centres from four health regions. Screening strategies were tested based on the WHO-5 questionnaire in association with a short structured interview based on ICD-10 criteria. Depression ICD-10 diagnosis was reached according to the gold standard SCAN interview performed by trained psychiatrists. Any depressive disorder ICD-10 diagnosis was present in 24.8% of patients. Through the use of favourable recognition criteria, 43% of the patients were correctly identified as depressed by their family doctor and about 13% of the depressed patients were prescribed antidepressants at an adequate dosage. The serial administration of both instruments – WHO-5 and short structured interview – was feasible, allowing the detection of eight in ten positive cases and the exclusion of nine in ten non-cases. In Portugal, at the primary care level, high depressive disorder prevalence is confirmed as well as the need to improve depression diagnostic and treatment competencies of family doctors. A two-stage screening strategy has been validated and seems adequate for systematic use in health centres where technical and organizational resources for the effective management of depression are made available. These results can be viewed as primary care depressive disorders baseline indicators of prevalence, detection and treatment and, along with clinical useful instruments, the health system is more capacitated for the establishment of a national level large education campaign on depression such as proposed in the National Health Plan 2004-2010.
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ABSTRACT Objective Investigate the occurrence of dual diagnosis in users of legal and illegal drugs. Methods It is an analytical, cross-sectional study with a quantitative approach, non-probabilistic intentional sampling, carried out in two centers for drug addiction treatment, by means of individual interviews. A sociodemographic questionnaire, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the Mini-International Neuropsychiatric Interview (MINI) were used. Results One hundred and ten volunteers divided into abstinent users (group 1), alcoholics (group 2) and users of alcohol and illicit drugs (group 3). The substances were alcohol, tobacco, crack and marijuana. A higher presence of dual diagnosis in group 3 (71.8%) was observed, which decreased in group 2 (60%) and 37.1% of drug abstinent users had psychiatric disorder. Dual diagnosis was associated with the risk of suicide, suicide attempts and the practice of infractions. The crack consumption was associated with the occurrence of major depressive episode and antisocial personality disorder. Conclusion It was concluded that the illicit drug users had a higher presence of dual diagnosis showing the severity of this clinical condition. It is considered essential that this clinical reality is included in intervention strategies in order to decrease the negative effects of consumption of these substances and provide better quality of life for these people.
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Adolescence corresponds to a transition period that requires adaptation and change capacities and skills. Most young people succeed with this challenge, whereas a minority fail. In order to identify with the teenage culture, become autonomous, and differentiate from their parents, some adolescents choose to use drugs, beginning with the use of cigarettes, alcohol, cannabis, followed by other illicit drugs such as opiates and stimulants. A high proportion of these adolescents attempt suicide, which is the primary cause of death during adolescence in many European countries. Who are the "vulnerable" adolescents? What are the mechanisms that can explain the varieties of drug-use initiation or suicide attempts? Can "protective factors" be identified? What kind of strategies might be developed at a social and political level in order to prevent or to minimize drug abuse and suicide attempts, among other harmful behaviors? These issues will be discussed on the basis of the recent literature and in the light of a recent study carried out in the French-speaking part of Switzerland on large cohorts of adolescent drug users. Unresolved critical issues are noted and future needed research is suggested.
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The treatment of delusional depression is a major challenge in psychopharmacology. Hypothalamic-pituitary-adrenocortical (HPA) overdrive may contribute, via increased dopaminergic activity, to the pathophysiology of the disorder. Trimipramine appears to be an interesting potential candidate, since it is an atypical antidepressant that is known to inhibit HPA activity. In a four-week open trial we investigated its effects in 15 inpatients with delusional depression. The dosage was increased within 7 days up to 300 - 400 mg/d and was then maintained for three weeks. Psychometric assessments and safety monitoring were conducted weekly. Assessment of the HPA activity was achieved by a combined dexamethasone suppression/corticotropin-releasing hormone stimulation (Dex/CRH) test before and after four weeks of treatment. Therapeutic response was defined as a decrease in the HAMD-score of at least 50 %. Eight out of 13 completers were rated as responders. Therapeutic response was associated with L, D-trimipramine concentrations higher than 160 ng/ml. Intent-to-treat analysis showed significant improvement in psychometric variables. Despite the high dosage, the substance was generally well tolerated, with the exception of one patient who suffered from a hypotensive reaction. Mean +/- SD concentration of L-trimipramine and D-trimipramine were 138 +/- 61 ng/ml and 119 +/- 50 ng/ml at a final dose of 346 +/- 50 mg/d. The ACTH and cortisol area under the curve in the Dex/CRH tests decreased significantly, reflecting a decrease of activity in the HPA system. We suggest that the clinical use of high-dose trimipramine in delusional depression seems to be a promising treatment strategy.
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We describe the case of a depressive patient who was a rapid metabolizer of CYP2D6 substrates and a heavy smoker, and who did not respond to several courses of treatment with antidepressants, as a result of unusually low drug-plasma levels. During hospitalization, he did not improve after treatment with clomipramine (150-225 mg/day during three weeks), but showed a response within four days after addition of fluvoxamine (100 mg/day). Plasma levels of clomipramine and desmethylclomipramine changed from 58 ng/ml and 87 ng/ml to 223 ng/ml and 49 ng/ml respectively one week after addition of fluvoxamine. Present knowledge of the role of cytochrome P-450 isozymes, such as CYP1A2, CYP2C19, CYP2D6, and CYP3A4, in the metabolism of psychotropic drugs as well as therapeutic drug-plasma level monitoring may thus help to determine individual treatment.
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BACKGROUND: Recent studies have reported alterations in protein kinase B (PKB)/Akt and in its downstream target, glycogen synthase kinase 3β, in depression and suicide. The aim of the present study was to investigate possible impairment of the upstream regulators, namely phosphatidylinositol 3-kinase (PI3K) and PTEN. METHODS: The ventral prefrontal cortex (Brodmann's area 11) of 24 suicide victims and 24 drug-free nonsuicide subjects was used. The antemortem diagnoses of major depression disorder were obtained from the institutional records or psychological autopsy, and toxicological analyses were performed. Protein levels of PI3K and PTEN were assayed using the immunoblot method, and the kinase activity of PI3K and Akt was determined by phosphorylation of specific substrates. RESULTS: A decrease was observed in the enzymatic activity of PI3K [ANOVA: F(3, 44) = 9.20; p < 0.001] and Akt1 [ANOVA: F(3, 44) = 13.59; p < 0.001], without any change in protein levels, in both depressed suicide victims and depressed nonsuicide subjects (p < 0.01 and p < 0.002, respectively). PTEN protein levels were increased in the same groups [ANOVA: F(3, 44) = 10.5; p < 0.001]. No change was observed in nondepressed suicide victims. CONCLUSION: This study concludes that attenuation of kinase activity of PKB/Akt in depressed suicide victims may be due to the combined dysregulation of PTEN and PI3K resulting in insufficient phosphorylation of lipid second messengers. The effect is associated with major depression rather than with suicide per se. Given the cellular deficits reported in major depression, the study of enzymes involved in cell survival and neuroplasticity is particularly relevant to neurotrophic factor dysregulation in depression.
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OBJECTIVE: In 2005-2006, several studies noted an increased risk of cardiovascular birth defects associated with maternal use of paroxetine compared with other antidepressants in the same class. In this study, the authors sought to determine whether paroxetine was associated with an increased risk of cardiovascular defects in infants of women exposed to the drug during the first trimester of pregnancy. METHOD: From teratology information services around the world, the authors collected prospectively ascertained, unpublished cases of infants exposed to paroxetine early in the first trimester of pregnancy and compared them with an unexposed cohort. The authors also contacted the authors of published database studies on antidepressants as a class to determine how many of the women in those studies had been exposed to paroxetine and the rates of cardiovascular defects in their infants. RESULTS: The authors were able to ascertain the outcomes of 1,174 infants from eight services. The rates of cardiac defects in the paroxetine group and in the unexposed group were both 0.7%. The rate in the database studies (2,061 cases from four studies) was 1.5%. CONCLUSIONS: Paroxetine does not appear to be associated with an increased risk of cardiovascular defects following use in early pregnancy, as the incidence in more than 3,000 infants was well within the population incidence of approximately 1%.
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The confinement can lead to an important limitation of sun exposure of the prisoners. This limitation can lead to a deficit in vitamin D, source of diverse disorders. Diffuse pains of members and of joints are the most classics troubles. The association of vitamin D deficiency and psychiatric disorders is frequent but badly known. Even if there is still no evidence indicating a cause and effect relationship between vitamin D deficiency and depressive episodes, the contribution of vitamin D deficiency in the arisen of a depression has to be considered. The treatment of vitamin D deficiency cannot, in itself, constitute a treatment of the depressive disorder but contributes to the improvement of the whole status The psychiatric follow-up remains indispensable, in particular because of the suicidal risk, particularly present in prison.
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Objective. The aim of this study is to analyse associations between eating behaviour and psychological dysfunctions in treatment-seeking obese patients and identify parameters for the development of diagnostic tools with regard to eating and psychological disorders. Design and Methods. Cross-sectional data were analysed from 138 obese women. Bulimic Investigatory Test of Edinburgh and Eating Disorder Inventory-2 assessed eating behaviours. Beck Depression Inventory II, Spielberger State-Trait Anxiety Inventory, form Y, Rathus Assertiveness Schedule, and Marks and Mathews Fear Questionnaire assessed psychological profile. Results. 61% of patients showed moderate or major depressive symptoms and 77% showed symptoms of anxiety. Half of the participants presented with a low degree of assertiveness. No correlation was found between psychological profile and age or anthropometric measurements. The prevalence and severity of depression, anxiety, and assertiveness increased with the degree of eating disorders. The feeling of ineffectiveness explained a large degree of score variance. It explained 30 to 50% of the variability of assertiveness, phobias, anxiety, and depression. Conclusion. Psychological dysfunctions had a high prevalence and their severity is correlated with degree of eating disorders. The feeling of ineffectiveness constitutes the major predictor of the psychological profile and could open new ways to develop screening tools.
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TERMINOLOGY AND PRINCIPLES OF COMBINING ANTIPSYCHOTICS WITH A SECOND MEDICATION: The term "combination" includes virtually all the ways in which one medication may be added to another. The other commonly used terms are "augmentation" which implies an additive effect from adding a second medicine to that obtained from prescribing a first, an "add on" which implies adding on to existing, possibly effective treatment which, for one reason or another, cannot or should not be stopped. The issues that arise in all potential indications are: a) how long it is reasonable to wait to prove insufficiency of response to monotherapy; b) by what criteria that response should be defined; c) how optimal is the dose of the first monotherapy and, therefore, how confident can one be that its lack of effect is due to a truly inadequate response? Before one considers combination treatment, one or more of the following criteria should be met; a) monotherapy has been only partially effective on core symptoms; b) monotherapy has been effective on some concurrent symptoms but not others, for which a further medicine is believed to be required; c) a particular combination might be indicated de novo in some indications; d) The combination could improve tolerability because two compounds may be employed below their individual dose thresholds for side effects. Regulators have been concerned primarily with a and, in principle at least, c above. In clinical practice, the use of combination treatment reflects the often unsatisfactory outcome of treatment with single agents. ANTIPSYCHOTICS IN MANIA: There is good evidence that most antipsychotics tested show efficacy in acute mania when added to lithium or valproate for patients showing no or a partial response to lithium or valproate alone. Conventional 2-armed trial designs could benefit from a third antipsychotic monotherapy arm. In the long term treatment of bipolar disorder, in patients responding acutely to the addition of quetiapine to lithium or valproate, this combination reduces the subsequent risk of relapse to depression, mania or mixed states compared to monotherapy with lithium or valproate. Comparable data is not available for combination with other antipsychotics. ANTIPSYCHOTICS IN MAJOR DEPRESSION: Some atypical antipsychotics have been shown to induce remission when added to an antidepressant (usually a SSRI or SNRI) in unipolar patients in a major depressive episode unresponsive to the antidepressant monotherapy. Refractoriness is defined as at least 6 weeks without meeting an adequate pre-defined treatment response. Long term data is not yet available to support continuing efficacy. SCHIZOPHRENIA: There is only limited evidence to support the combination of two or more antipsychotics in schizophrenia. Any monotherapy should be given at the maximal tolerated dose and at least two antipsychotics of different action/tolerability and clozapine should be given as a monotherapy before a combination is considered. The addition of a high potency D2/3 antagonist to a low potency antagonist like clozapine or quetiapine is the logical combination to treat positive symptoms, although further evidence from well conducted clinical trials is needed. Other mechanisms of action than D2/3 blockade, and hence other combinations might be more relevant for negative, cognitive or affective symptoms. OBSESSIVE-COMPULSIVE DISORDER: SSRI monotherapy has moderate overall average benefit in OCD and can take as long as 3 months for benefit to be decided. Antipsychotic addition may be considered in OCD with tic disorder and in refractory OCD. For OCD with poor insight (OCD with "psychotic features"), treatment of choice should be medium to high dose of SSRI, and only in refractory cases, augmentation with antipsychotics might be considered. Augmentation with haloperidol and risperidone was found to be effective (symptom reduction of more than 35%) for patients with tics. For refractory OCD, there is data suggesting a specific role for haloperidol and risperidone as well, and some data with regard to potential therapeutic benefit with olanzapine and quetiapine. ANTIPSYCHOTICS AND ADVERSE EFFECTS IN SEVERE MENTAL ILLNESS: Cardio-metabolic risk in patients with severe mental illness and especially when treated with antipsychotic agents are now much better recognized and efforts to ensure improved physical health screening and prevention are becoming established.