Depressive disorders among older residents in a Chinese rural community. Risk for Depression by Age and Sex. Risk for Depression by Age and Sex
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1 Risk for Depression by Age and Sex Risk for Depression by Age and Sex Depressive disorders among older residents in a Chinese rural community. Liu CY, et al: Psychological Medicine 1997:27: Male MDD 26 (4.5%) Other Depressive disorders 32 (5.5%) Non case 526 Female 54 (7.5%) 57 (7.9%) 618 X 2 =8.31, p=0.015
2 Definition of nature menopause the permanent cessation of menstruation, determined retrospectively after 12 consecutive months of amenorrhea without any other pathological or physiological cause - WHO, 1996 Definition of Peri-menopause The period (2-8 years) preceding menopause and one year after final menses. - WHO, 1996 Most prevalent mood symptoms during this period: irritability, tearfulness, anxiety, depression, labile mood, lack of motivation, lack of energy, poor concentration and interrupt sleep. - Steiner, et al., 2003 related to fluctuations in estradiol, especially withdrawal from very high erratic level. - Prior, 1998 Most prevalent mood symptoms during this period: and - Steiner, et al., 2003 related to fluctuations in estradiol, especially withdrawal from very high erratic level. - Prior, 1998, 2008
3 Symptoms in menopausal women (Taiwan, ) Lower back pain Fatigue Decreased memory Vaginal dryness Hot flashes Insomnia Loss of libido Dry skin Depression 68% 59% 55% 50% 49% 46% 46% 41% 40% Chow SN, et al: J Formosan Medical Association Pan HA, Maturitas 41 (2002) Avis, et al., 2005 Avis, et al., 2005 Peri Menopausal / Menopausal symptoms A psychoneuroendocrine mechanism triggered by the normal endocrine events Genetic predisposition Neurotransmitters Ovarian hormone Estrogen = (serotonergic activity) = (noradrenergic activity) = (D2 sensitivity) Lewis-Hall F, et al., Garlow et al,, 1999 ; Soares et al,, 2003
4 Estrogen = serotonin = norepinephrin = D2 Dysregulation of Neurotransmitters Involved in Mood Symptoms 5-HT-related Obsession Compulsion Depression Anxiety Panic Phobia NE-related B
5 NICE guideline for treatment of GAD (2004) 1. Immediate management, any or all of the following support and information problem solving benzodiazepines sedative antihistamines self help 2. BZDs should not usually be used beyond 2-4 weeks. 3. Longer-term management CBT antidepressant medication self-help NICE guideline for treatment of PD (2004) Anxiety level Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder. The interventions that have evidence for the longest duration of effect: psychological therapy ( CBT) pharmacological therapy (antidepressants) self-help Symptom intensity GAD Panic disorder Normal Time Anxiolytic Medications for use in medical outpatients Medications First line Paroxetine (SSRI) Fluoxetine (SSRI) Citalopram (SSRI) Sertraline (SSRI) Venlafaxine (SNRI) Second line Bupropion (NDRI) Fluvoxamine (SSRI) Nefazodone (SARI) BZDs (lorazepam, clonazepam, Starting dose 25mg/d 37.5mg/d 100mg/d 100mg/d alprazolam, Step-up dose 10-20mg/d 10-20mg/d 25mg/d 37.5mg/d etc Target dose 40mg/d 20-40mg/d 20-40mg/d 100mg/d Top dose 40mg/d 80mg/d 60mg/d 200mg/d 225mg/d 4 300mg/d 600mg/d Dysregulation of Neurotransmitters Involved in Mood Symptoms 5-HT-related Obsession Compulsion Depression Anxiety Panic Phobia NE-related Rollman, et al., Gen Hosp Psychiatry, 2003
6 (antidepressants -- SNRI, SSRI) (SNRI, SSRI) (benzodiazepines, BZDs) (SNRI, SSRI) (BZDs) (HT) / / sedative antidepressants Neurotransmitters and hot flashes Hot flashes are the primary symptoms of the menopausal transition. Related to the dysregulation of the thermoregulatory center in the hypothalamus. Cohen, et al., 2005 estrogen withdrawal leads to a decreased serotonin blood level and an increased 5-HT 2A receptor sensitivity in the hypothalamus (involved in thermoregulation). Berendsen, 2000 hot flushes are triggered within the hypothalamus through the action of alpha 2-adrenergic receptors on noradrenergic neurons. Freedman, et al., 1990 SIKON & THACKER, 2004
7 BPH ( ) (SNRI, SSRI) (estrogen augmentation for treatment refractory patients if needed) Thank You for Your Attention, 着 (HT) (SNRI, SSRI) (gabapentin) Chia-Yih Liu
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