Diagnosing Mood Disorders (cont.)

Depression in Pregnancy and Postpartum Depression

Question 4:

You have a 28 year old woman who is in her third trimester of pregnancy. She has been diagnosed with severe depression and is under the care of a psychiatrist. She wants to discuss with you the risk of taking antidepressants during the rest of her pregnancy. Which of one of the following statements istrue(Choose the best answer.)

  1. If she takes an SSRI (selective serotonin reuptake inhibitor), her newborn has a risk of developing transient “poor neonatal adaptation”.
  2. If she takes an SSRI (selective serotonin reuptake inhibitor), her newborn has a small risk of developing a permanent serotonin syndrome.
  3. Dilantin does not have teratogenic effects.
  4. Tricyclic antidepressants cause fetal structural malformations.

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Although depression in pregnancy and postpartum depression is beyond the scope of this web module, it is important for primary care physicians to be aware of screening these patients for timely intervention.

Medical management of depressed patients during pregnancy usually stirs discomfort in physicians because of fear of teratogenic effects in the fetus. Adverse effects of not treating this population are well documented, as well as the safety profiles of commonly prescribed psychiatric medications. Selective serotonin reuptake inhibitors are the agents of choice. Fluoxetine and tricyclic antidepressants appear to have no teratogenic effects, however the Food and Drug Administration (FDA) has determined that exposure to paroxetine in the first trimester of pregnancy may increase the risk for congenital malformations, particularly cardiac malformations. However, this absolute risk (AR) remains very small: the AR increases with 3rd trimester paroxetine use from 1 to 2 per 1000 (0.1-0.2%) to 3 to 12 per 1000 (0.3-1.2%). There is a small but significant risk of “poor neonatal adaptation” in the newborn if serotonergic antidepressants are taken during the third trimester. This cluster of mild symptoms lasts less than two weeks and consists of irritability, tachypnea, thermal instability, and a weak or absent cry. The majority of studies have not shown an association between tricyclic antidepressant (TCA) use in pregnancy and structural malformations. The mood stabilizers (e.g. dilantin, valproic acid, carbamazepine) appear to be teratogenic.

Overall, pregnant patients, once identified with depression, should be under the care of a psychiatrist and an obstetrician or family physician with experience in high risk obstetrics. Psychotherapy has also been found to be useful in these women. The decisions regarding the use of psychiatric medications should be individualized, and made with support from a psychiatrist. The most important factor is usually the patient’s level of functioning in the past when she was not taking medications. Psychotherapy has also been found to be useful in these women–and in fact should be considered as the first line of treatment for pregnant patients with mild to moderate depression which has been successfully treated in the past with or without medication. In general, pregnant patients with a history of bipolar disease, suicide attempts, recurrent MDD or psychotic disorders are recommended to continue their medications through the pregnancy under close supervision from both her psychiatrist and obstetrician.

Postpartum depression typically occurs within one month of delivering a baby. Normal “baby blues” can begin 24 hours after delivery and last up to 10 days. Postpartum depression is not different from a major depressive episode, but the primary care physician or obstetrician should recognize the symptoms as immediate interventions can have positive outcomes for the mother and baby. One important challenge is that the onset of postpartum depression frequently occurs before the patient is seen for a routine six-week postpartum visit. The risk-benefit decision about whether to start antidepressants in a breastfeeding woman is based on the severity of the depression and the need for pharmacotherapy, rather than any known risks to the infant.

More information on treatment of depression in pregnancy, postpartum women, and breastfeeding woman can be found in this web module’s library.

Depression in the Elderly and Pseudodementia

Question 5:

Which one of the following statements is true about depression in the elderly? (Choose the best answer.)

  1. Physicians are more likely to diagnose depression correctly in the elderly than in younger people.
  2. Depression in the elderly is less important than in younger patients because depression is a normal part of the aging process.
  3. Patients who are elderly when their first depressive episode occurs have a relatively high likelihood of developing recurring chronic depression.
  4. Risk factors for depression in elderly persons include a history of depression, chronic medical illness, male sex, being single or divorced, brain disease, alcohol abuse, use of certain medications, and stressful life events..
  5. The long term prognosis for the elderly suffering from depression is poor even with treatment.

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Depression in the elderly is not part of the normal aging process. This common misconception may lead elderly patients, or their families, not to seek appropriate help. It can also lead physicians to miss the diagnosis of depression in the elderly and leave it untreated. A common complaint in elderly patients is not depression but insomnia, anorexia, and fatigue. Treatment with antidepressants, especially selective serotonin reuptake inhibitors can be useful. Patients who are elderly when they have their first episode of depression have a relatively higher likelihood of developing chronic and recurring depression. The prognosis for recovery is equal in young and old patients, although remission may take longer to achieve in older patients.

Pseudodementia, associated with severe depression, can be easily mistaken for dementia, especially in the elderly or persons with underlying neurological disease (e.g., strokes, etc). The symptoms of pseudodementia include marked psychological distress, inability to concentrate or complete daily tasks, and marked cognitive dysfunction. Differentiating between dementia and pseudodementia is important. Typically, patients suffering from pseudodementia will exhibit profound concern about their impaired cognitive function, in contrast with patients with a diagnosis of dementia, who may tend to minimize their disability. In addition to pharmacotherapy, electroconvulsive therapy may be warranted in patients with pseudodementia.

All patients with depression of all ages, including the elderly, should have a mini-mental status examination at baseline. Patients successfully treated of their major depression will see their pseudodementia and cognitive dysfunction improve.

Differentiating Dementia and Depression
Characteristic Dementia Depression
Onset Insidious, indeterminate Relatively rapid, associated with mood changes
Duration of symptoms Usually long Usually short
Orientation, mood, behavior, affect Impaired, inconsistent, fluctuating Intact, diurnal variation depressed/anxious, complaints worse than on testing
Cognitive impairment Consistent; stable or worsening Inconsistent, fluctuating
Neurologic defects Often present (e.g. agnosia, dysphasia, apraxia) Absent
Disabilities Concealed by patient Highlighted by patient
Depressive symptoms Present Present
Memory impairment Doesn’t remember recent events, often unaware of memory loss. Onset of memory loss occurs before mood change. Concentration poor, patient complains of memory loss of recent and remote events, follows onset of depressed mood
Psychiatric history None Often, history of depression
Answers to questions Near answers “Don’t know” answers
Performance Tries hard but is unconcerned about losses Does not try hard but is more distressed by losses
Associations Unsociability, uncooperativeness, hostility, emotional instability, reduced alertness, confusion, disorientation Appetite and sleep disturbances, suicidal thoughts
Reproduced with permission from Birrer, R., Vemuri, S. “Depression in Later Life: A Diagnostic and Therapeutic Challenge.” American Family Physician. 2004;69:2375-82.

More information on depression in the elderly is available in this web module’s library.

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