Differential Diagnosis of Depression

Mimicking Condition
Substance abuse Alcohol Cocaine CNS stimulants Marijuana Anemia

Symptoms
Depression Mood changes Apathy Loss of energy Fatigue Apathy Depression Apathy Depression Depression Mood Changes Loss of appetite Apathy

Differentiators
Medical history Family history Blood screen Urine screen Hemoglobin Hematocrit Thyroid function tests Medical history CT scan MRI Ultrasound

Hyperthyroidism/Hypothyroi dism Neoplasia

Differential Diagnosis of Depression

Mimicking Condition
Medications Corticosteroids Beta- blockers Estrogen Benzodiazepines
Chronic illnesses TB AIDS Arthritis Trauma Brain injury Injuries CNS disease Parkinsons Alzheimer s

Symptoms
Depression Fatigue Mania

Differentiators
Medical history

Fatigue Loss of appetite Anxiety Depression Apathy Loss of appetite Major Depression Major Depression Apathy

Medical History Laboratory findings Imaging techniques Medical history CT scan, MRI, PET scan Medical history Neurological Exam MRI, EMG, CT scan

Psychotherapy for Depression

Mild depression Has a strong placebo response, so treatment with psychotherapy is a good idea. Moderate depression 70% response with cognitive-behavioral therapy, interpersonal treatment, and anti-depressants

Severe depression Psychotherapy alone not recommended for these patients.

Electroconvulsive Therapy (ECT)

Oldest and most effective treatment for depression better than any other treatment Done on least 100,000 patients in the U.S. every year Produces a generalized cerebral seizure while the patient is under general anesthesia. Patients typically begin to respond after two to four treatments First-line treatment in certain urgent clinical situations

Electroconvulsive Therapy

http://effectivehealthcare.ahrq.gov/tasks/sites/ehc/assets/Image/ElectroconvulsiveTherapy.png

Indications for ECT

Life-threatening depression Inability to take medication Contraindications to medication Lack of response to medication Pregnant and lactating can be effectively and safely treated with ECT. Significantly decreased mortality in elderly patients hospitalized for depression compared with antidepressant medication. Children rarely used

Contraindications
Unstable or severe cardiovascular disease Intracranial lesion with evidence of elevated intracranial pressure Recent cerebral hemorrhage or stroke Bleeding or otherwise unstable vascular aneurysm Severe pulmonary condition

ECT Risks
2 to 4 deaths per 100,000 treatments - one of the safest procedures performed under general anesthesia Mostly due to cardiopulmonary events Acute confusion: Resolves 10-30 minutes after the procedure. Anterograde amnesia - Resolves within two weeks Retrograde amnesia - Most deficits involve public or world events (impersonal memory); some memories permanently lost - tradeoff

Ablation Neurosurgery
Very last resort Heavily restricted use No established criteria to become candidate clinical judgment Independent review boards usually involved to ensure all other treatments have failed Done through craniotomy Interrupt abnormal communication between grey matter regions by severing white matter connections Improvement from baseline on the depression rating scale of 50% or greater

Ablation Neurosurgery
Reserved for patients with major depression who are resistant to multiple courses of treatment including: Antidepressants at least 4, 4-8 weeks each Antidepressants plus an augmentation agent (eg. Second-generation antipsychotic, lithium) Psychotherapy added onto pharmacotherapy at least 3 trials Non-invasive neuromodulator (eg. ECT) at least 1 course

Ablation Neurosurgery
Severe personality disorders Comorbid substance use disorders Suicidal ideation or behavior Chronic, poorly controlled general medical conditions Previously diagnosed intracranial masses Intracerebral vascular abnormalities Pregnancy

Craniotomy

http://www.hopkinsmedicine.org/sebin/t/w/craniotomy-procedure.jpg

Surgery Risks
Intracranial bleeding Infection Anesthesia complications Delirium Epilepsy Impaired cognition (including executive functioning, memory, set shifting, and verbal fluency) Personality changes (eg, impulsivity, disinhibition, and amotivation) Weight gain Urinary incontinence (typically transient)

References
American Psychiatric Association Task Force on Electroconvulsive Therapy. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. American Psychiatric Association, Washington, DC 2001. Flint AJ, Gagnon N. Effective use of electroconvulsive therapy in late-life depression. Can J Psychiatry 2002; 47:734-741. Anderson EL, Reti IM. ECT in pregnancy: a review of the literature from 1941 to 2007. Psychosomatic Med 2009; 71:235-242. UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361: 799-808.

Tess AV, Smetana GW. Medical evaluation of patients undergoing electroconvulsive therapy. N Engl J Med 2009; 360:1437-1444.

Tew JD, Mulsant BH, Haskett RF, et al. Acute efficacy of ECT in the treatment of major depression in the old-old. Am J Psychiatry 1999; 156: 1865-1870. Datto CJ. Side effects of electroconvulsive therapy. Depression and Anxiety 2000; 12: 130-134. Lisanby SH, Maddox JH, Prudic J, et al. The effects of electroconvulsive therapy on memory of autobiographical and public events. Arch Gen Psychiatry 2000; 57: 581-590. Ovsiew J, Frim DM. Neurosurgery for psychiatric disorders. J Neurol Neurosurg Psychiatry 1997; 63:701-705. McFarquhar TF, Thompson J. Knowledge and attitudes regarding electroconvulsive therapy among medical students and the general public. J of ECT 2008; 24 (4): 244-253. Marino RJ, Cosgrove GR. Neurosurgical treatment of neuropsychiatric illness. Psyc Clin of N Amer 1997; 20(4):934-943.