Depressive disorders case example

The anxiety disorders are a case in point. They comprise a range of conditions contiguous with the affective disorders and the stress responses (Table 4.1). Much overlap and comorbidity exist. Furthermore, definitions and diagnostic criteria have changed substantially over the years. For example, generalized anxiety disorder is a rare condition in its pure form, but a common condition if comorbid phobic and depressive disorders are accepted. 

Third is the presence of other psychiatric or medical disorders. This can help gnide antidepressant selection in several ways. In some cases, an antidepressant may be preferred becanse it can treat both disorders. For example, the extensive evidence that flnoxetine is an effective treatment for bnlimia nervosa makes it preferable for patients with depression and bnlimia. Similarly, the depressed Parkinson s disease patient whose nenrological illness results from a lack of dopamine in a particular area of the brain may have both her depression and her Parkinson s disease improved by bnpropion, which increases brain dopamine activity. In other cases, an antidepressant shonld be avoided if it worsens the other illness or interacts adversely with a medication needed to treat the other illness. For example, TCAs and MAOIs can complicate glncose control in diabetics and shonld not rontinely be used by depressed diabetics. (See Table 3.11.)... 

Manic attacks are usually a component of what is called bipolar, or manic-depressive, disorder periodic episodes of depression often arc experienced by these individuals as well. The following case (Spitzer et al., 1989) illustrates the manic component of bipolar disorder. It is an example of the development of manic symptoms late in life. 

Part II of the book outlines several mental-health diagnostic categories schizophrenia, mood disorders, depression, bipolar disorders, and specific anxiety disorders including generalized anxiety disorder and obsessive compulsive disorder. Each chapter provides a case example, consideration in diagnosis, and the interventions utilized. Medications used to treat these disorders and relevant psychosocial interventions are outlined. Each chapter emphasizes the need for accurate treatment planning and documentation and offers suggestions to facilitate this process. 

In addition, it exerts beneficial effects in many disorders as an adjuvant to other treatment modalities. Such effects are apparent only if it is administered to an already pharmacologically treated patient. For example, in unresponsive major depressive disorder, the co-administration of lithium to an ongoing antidepressant treatment increases the response rate by up to 50%. In most cases, the response to lithium augmentation is either considerable or not at all ( all-or-none phenomenon). Some (currently not convincing) results have also been reported in unipolar depression, bulimia nervosa, and attention deficit hyperactivity disorder (ADHD). Lithium also exerts antiaggressive effects in conduct disorder, independent of any mood disorder, and can reduce behavioral dyscontrol and self-mutilation in mentally retarded patients. One of the most striking effects of lithium is its antisuicidal effect in patients who suffer from bipolar and unipolar depressive disorder irrespective of comorbid axis I disorder. ... 

Numerous reports of altered neurotransmitter and hormone functions which have been associated with the affective disorders are reviewed by Levell [142]. It was originally proposed that one or more of the neurotransmitter amines in the brain (norepinephrine, dopamine, serotonin) may be functionally elevated in manic patients and reduced in depressed patients [143]. For instance, an increase in the production of dopamine, observed in a number of case reports, is thought to be the cause of the switch into the manic phase in bipolar patients. For example, Bunney et al. reported an increase in the level of homovanillic acid (HVA), a... 

In some cases, anxiolytics serve a transitional purpose. For example, for a patient with acute-onset panic disorder, severe anticipatory anxiety, and a family history of depression, administration of an antidepressant medication that also has antipanic effects may be the optimal treatment, but this will not help the patient for several weeks, during which time there is a risk of progression to agoraphobia. For this patient, starting antidepressant therapy and also attempting to obtain acute symptom relief with a benzodiazepine may be helpful. After 4 weeks, the benzodiazepine dose should be slowly tapered so that the patient s condition is controlled with the antidepressant alone. 

Paradoxically, ECT is equally useful in both the acute manic and depressive phases of bipolar disorder, constituting the only truly bimodal therapy presently available. For example, in their literature review, Mukherjee et al. ( 51) found that ECT was associated with marked clinical improvement or remission in 80% of patients undergoing treatment for an acute manic episode. This is not the case for lithium, valproate, or CBZ, which, at best, have relatively weak acute antidepressant effects. Drug therapies may also induce a switch from a depressed to a manic phase, whereas ECT can control both phases of the illness. 

It appears that a number of complications await the recovering bipolar patient after an episode of mania. For example, Lucas et al. ( 44) reported on a retrospective linear discriminant analysis of 100 manic episodes (1981 to 1985) during the recovery phase and found that the incidence of subsequent depression was 30% in the first month. Many episodes were transient, however, and did not necessarily require treatment. This phenomenon could be successfully predicted in 81% of cases in which there is a premorbid history of cyclothymia with either a personal or a family history of depression. The highly significant association between family history and postmanic depression again supports the hypothesis of a genetic basis for bipolar disorder. 

It is possible that what initially appear to be characteristic symptoms of personality disorder may reflect some form of mild, chronic, or atypical Axis I disorder. Let s consider several examples. For years clinicians described certain patients as suffering from masochistic or depressive personalities. These people were often seen as chronically pessimistic, bitter, irritable individuals, and the implication was that the low-grade depressive traits were manifestations of personality— that is, etched into the character of the individual. Although certainly this is the case for some people, in recent years a significant number of dysthymic patients have experienced very positive results when treated with antidepressants. 

Classic reactive depressions (sometimes referred to as psychological depressions) can range in intensity from mild or moderate (for example, adjustment disorders with depressed mood) to severe (major depression). These disorders occur in response to identifiable psychosocial stressors. These stressors may be acute and intense (such as loss of a loved one), insidious (as in the case of a gradual deterioration in the quality of marital relationship), or in the distant past (for example, the emotions experienced by a survivor of child abuse who in adulthood begins to recall long-forgotten abusive events). 

Furthermore, a diet with low contents of FA may be involved in the development of insulin resistance, which suggests that an appropriate dietary intake of n-3 PUFA is considered protective against metabolic syndrome [183]. In addition, diverse psyquiatric impairs (depression, bipolar disorders, schizophrenia, autism) and neurodegenerative diseases such as Alzheimer disease have been associated to decreased blood levels of n-3 HUFA. Besides, there are many examples about the use of pol)nmsaturated FA as drugs. Thus, EPA has shown efficacy as adjunctive treatment, and in some cases as the only treatment in several psyquiatric disorders [184]. It is suggested that the potential of n-3 FA to prevent recurrence and metastasis of mammary cancer when used in adjuvant therapy is associated with a n-6 to n-3 ratio lower than 2 1 [185], On the other hand, fish intake is considered as a protective factor for preventing prostate cancer in addition, in humans low levels of ALA in mammary adipose tissue are associated with an increased risk of breast cancer in women [186]. 

In some cases, the pharmacology of the variants has not been fully characterized. For example, while the 524C>A, Leul33Ile CB2 variant has been associated with bipolar disorder, the pharmacological consequences of the variant are not fully unknown [306], By contrast, the CB2 variant, 315A>G, has been associated with major depression (MD) in Japanese population by [307]. 

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