Depression and Seasonal Affective Disorder

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Depression and Seasonal Affective Disorder

• Lisa L. Willett, MD
• December 11, 2007
• Common Ambulatory Topics Seminar
• General Medicine Noon Conference

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Why do I care?

• Prevalent
• Unrecognized depression seeks medical attention
  more often (physician, cost)
• Fourth leading cause of disability
• Second only to heart disease
• Marked suffering, increased mortality
• Treatment is effective

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Case

• 47 yoF complains of fatigue
• Irritable, short tempered
• No energy, wants to sleep all day
• Stressed
• Shopping, decorating, cooking, cleaning
• Works full time, 4 kids, lazy husband
• Family strife (in-laws are coming to visit)

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Common Clinical Questions

• Does she have major depression
• most important screening questions
• Does she have seasonal affective disorder
• Does she require medications
• Is she at risk for suicide

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DSM-4 CriteriaMajor Depression (gt5, gt2weeks)

• Depressed mood
• Anhedonia

• Sleep disturbance
• Appetite or weight change
• Fatigue or loss of energy
• Psychomotor activity
• Decreased concentration
• Guilt or worthlessness
• Suicidal ideation

Williams, Rational Clinical Examination, JAMA
2002.2871160-70
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Depressed Mood

• How is your mood?
• Do you ever feel down or depressed or blue?
• How often does it happen?
• How long does it last?
• Most of the day, nearly every day

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Anhedonia

• What do you do for fun?
• Have you lost interest in your usual activities?
• Do you get less pleasure in things you used to
  enjoy?
• Diminished pleasure in almost all activities most
  of the day, nearly every day

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Screening Instruments

• Multiple questionnaires, from 1-30 items
• Administration time lt 1 to 5 minutes
• Patient Health Questionnaire (PHQ)-9, -2
• Short Form General Health Survey (SF-20)
• Variable performance, overall similar
• Consider time, desire to screen for other
  psychiatric illnesses, monitor responses

Williams, Rational Clinical Examination, JAMA
2002.2871160-70
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Grulke, Wien Med Wochenschr 2005155(13-14)297-30
2 Whooley, JGIM 199712(7)439-45 Springer, JGIM
2007 May 22(5) 677680
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Seasonal Affective Disorder

• Definition the seasonal pattern of major
  depressive episodes
• Recurring depression with seasonal onset
• Full remission
• 2 patterns
• Summer-onset typical depression symptoms
• Fall-onset (winter depression) - atypical

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Seasonal Affective Disorder

• Data very limited
• More common in young women, age 23
• Decreasing daylight, abnormal melatonin?
• Longer, more severe with higher latitudes
• Responds to light therapy
• Associated with alcohol, ADHD, anxiety/panic
• Decreased central serotonergic activity
• HTR2A gene (codes for serotonin receptor)

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Clinical Features Fall onset

• Atypical depression symptoms
• Increased sleep
• Increased appetite
• Irritability
• Markedly increased weight
• Interpersonal difficulties (rejection
  sensitivity)
• Leaden paralysis
• heavy, lead in arms/legs

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Therapy

• Light therapy
• Cognitive behavioral therapy
• Pharmacotherapy

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Light Therapy
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Cognitive behavioral therapy
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Pharmacotherapy Indications

• Prior positive response to antidepressants
• High suicide risk
• Significant functional impairment
• Moderate to severe recurrent depression
• Patient preference
• Failed light therapy or psychotherapy

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Drugs

• Treatment
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Prevention
• Wellbutrin XL (bupropion HCL extended-release
  tablets)
• Depression free at end of treatment 84 vs. 72
  placebo

Lurie, Am Fam Physician 2006741521-24 http//www
.fda.gov/fdac/departs/2006/506_upd.html
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Does she have seasonal affective disorder?
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Case

• 47 yoF complains of fatigue
• Irritable, short tempered
• No energy, wants to sleep all day
• Stressed
• Shopping, decorating, cooking, cleaning
• Works full time, 4 kids, lazy husband
• Family strife (in-laws are coming to visit)

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Major Depression (gt5, gt2weeks)

• Depressed mood
• Anhedonia

• Sleep disturbance
• Appetite or weight change
• Fatigue or loss of energy
• Psychomotor activity
• Decreased concentration
• Guilt or worthlessness
• Suicidal ideation

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Case, cont

• Major Depression?
• Feel down, dont enjoy the season anymore for
  about 3 weeks
• Tired, I want to sleep all day
• Fatigued, no energy
• Stressed
• Eat more, gain weight
• Quit exercising

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Major Depression (gt5, gt2weeks)

• Depressed mood
• Anhedonia

• Sleep disturbance
• Appetite or weight change
• Fatigue or loss of energy
• Psychomotor activity
• Decreased concentration
• Guilt or worthlessness
• Suicidal ideation

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Case

• 47 yoF complains of fatigue
• Irritable, short tempered
• No energy, wants to sleep all day
• Stressed
• Shopping, decorating, cooking, cleaning
• Works full time, 4 kids, lazy husband
• Family strife (in-laws are coming to visit)

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Clinical Features Fall onset

• Atypical depression symptoms
• Increased, not decreased, sleep
• Increased, not decreased, appetite
• Markedly increased weight
• Irritability
• Interpersonal difficulties (rejection
  sensitivity)
• Leaden paralysis (heavy, lead in arms/legs)

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How would you treat her?Does she require
medications?
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Therapy

• Light therapy
• Cognitive behavioral therapy
• Pharmacotherapy
• SSRI Fluoxetine (Prozac) ,Sertraline (Zoloft)
• Prevention next year (buproprion)
• Dont forget bipolar disorder
• Dont forget to ask about suicide

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Suicide

• Patients rarely volunteer - ask directly
• Major risks
• prior suicide attempts, family history of suicide
  
• substance abuse
• physical illness (HIV, cancer, asthma)
• poor functional capacity, hopelessness
• pyschiatric history
• sociodemographics

Spring, JGIM 200722677-680
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Who is at most risk?

• Despite medical illnesses, suicide is most often
  related to unrecognized co-morbid psychiatric
  illness
• Most often depression
• Sociodemographics
• Social isolation
• Age over 60
• Male
• White or Native American

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Screening Questions

• Have you been feeling that life is not worth
  living or that you would be better off dead?
• Sometimes when a person feels down or depressed,
  they might think about dying. Have you been
  having any thoughts like that?

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If yes

• Do you have a plan?
• Ask if materials assembled, time set, factors
  that may precipitate or prevent patient from
  carrying out
• Urgent/emergent psychiatry evaluation
• SSRIs controversy of increased attempts
• Evidence does not support withholding treatment

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Common Clinical Questions

• Does she have major depression
• most important screening questions
• Does she have seasonal affective disorder
• Does she require medications
• Is she at risk for suicide

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