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Adherence to long-term therapy for chronic illnesses in developed countries averages 50%. In developing countries, the rates are even lower. Noncommunicable.

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Presentazione sul tema: "Adherence to long-term therapy for chronic illnesses in developed countries averages 50%. In developing countries, the rates are even lower. Noncommunicable."— Transcript della presentazione:

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2 Adherence to long-term therapy for chronic illnesses in developed countries averages 50%. In developing countries, the rates are even lower. Noncommunicable diseases (cancer, hypertension, diabetes,etc) Mental disorders, human immunodeficiency virus/acquired immunodeficiency syndrome and tuberculosis, together represented 54% of the burden of all diseases worldwide in 2001 and will exceed 65% worldwide in 2020.

3 La Depressione : definizione La depressione come fenomeno appare di non facile definizione, in quanto legata indissolubilmente al concetto di umore. Lumore è una dimensione complessa della vita psichica delluomo, nella quale confluiscono aspetti emozionali, affettivo/sentimentali, cognitivi, temporali, motivazionali e motori che, se così si può dire, colora di sé tutta la vita dellindividuo, costituendo una sorta di griglia percettiva ed elaborativa con cui si dà significato alla realtà. (Vella, Siracusano1994)

4 La Depressione : definizione Esiste una linea di continuità che collega la depressione tristezza, sia alla tristezza, esperienza comune e fisiologica, dolore, sia al dolore, che rappresenta a sua volta uno dei nulei centrali della depressione. La qualità che fa traghettare dolore e tristezza nella depressione può pervasività,nellinteressare psiche e soma essere riconosciuta nella loro pervasività, nellinteressare psiche e soma fissitànon essere più modificabilidalle allo stesso modo, nella loro fissità, nel non essere più modificabili dalle situazioni esterne,nellintensità del dolore, situazioni esterne, tristi o liete, nellintensità del dolore, che tende a congelare vissuti psichici e somatici in un unico blocco privo di spintaevolutiva. privo di spinta evolutiva.

5 Depressione e suicidio 10-15% dei pazienti depressi si suicida I due terzi tra i pazienti depressi hanno idee suicide I pazienti depressi con aspetti psicotici considerano talvolta luccisione di persone coinvolte nei loro sistemi deliranti

6 Population projection of US adults with lifetime experience of depressive disorder by age and sex from year 2005 to 2050 (I). In year 2006 the (weighted) prevalence of lifetime experience of depressive disorder was 15.7% among 188,292 respondents aged 18 years or older. Female prevalence was 20.6%, which was about twice as high as the prevalence among males (11%). Heo M,, Murphy CF ET AL.Int J Geriatr Psychiatry May 23. [Epub ahead of print]

7 Population projection of US adults with lifetime experience of depressive disorder by age and sex from year 2005 to 2050 (II). From year , the total number of US adults with depressive disorder will increase from 33.9 million to 45.8 million, a 35% increase. The increase is projected to be greater in the elderly population aged >/= 65 years ( , a 117% increase???) than in the young population aged < 65 years ( , a 25% increase). Heo M,, Murphy CF ET AL.Int J Geriatr Psychiatry May 23. [Epub ahead of print]

8 Depressione e suicidio 10-15% dei pazienti depressi si suicida I due terzi tra i pazienti depressi hanno idee suicide I pazienti depressi con aspetti psicotici considerano talvolta luccisione di persone coinvolte nei loro sistemi deliranti

9 Gender differences in health status In industrialized countries males tend to die earlier than females and females tend to have greater longevity but higher rates of morbidity (Okojie, 1994; Stein, 1997; Lewis, 1998) This female advantage is a relatively recent phenomenon and female excess mortality, which defined many western societies prior to the industrial revolution, still pertains in many less developed countries today ( Annandale, 1998)

10 Prevalenza della depressione (National Comorbidity Survey)

11 Prevalence of Depression: Women compared to Men Major depression is a TREATABLE major public health problem in women Annual Lifetime Women 13% 21% Men 8% 12% The rate of MD for women rises dramatically above that for men during and after puberty (with two peaks - childbearing years and perimenopausal transition) and then actually falls after menopause

12 Gender Differences in Prevalence of Major Depression Women: X rate relative to men during ages Kessler et al (1993) Journal of Affective Disorders

13 The rate of MD for women rises dramatically above that for men during and after puberty (with two peaks - childbearing years and perimenopausal transition) and then actually falls after menopause Puberal status, puberal timing,age, hormonal mechanisms (Angold) Difficulties with self- image, temperament and early sexuality (Stattin and Magnusson) New, hormonally driven needs for affiliation, difficulties with the transition to adolescence negative life events (Cyranowski) Girls who lack healthy parental attachments anxious or inhibited temperament failed to develop good coping skills (Cyranowski) Genetic loading negative life events (Silberg, Pickles, Rutter) History of MD, traumatic experiences, genetic factors, temperament (Kendler)

14 Reproductive Hormones and Neurotransmitters Effects of Estrogen Synapse formation Activates mature neuronal cells Increases sensory perception Increases cerebral perfusion Augments central nervous system glucose use Alters pain pathways

15 Differences between Males and Females in Rates of Serotonin Synthesis in Human Brain Nishizawa S, Benkelfat C, Young SN, et al. Proc Natl Acad Sci USA 1997; 94 (10):

16 DEPRESSIONE NELLA DONNA IPOTESI TEORICHEFasi vita Fasi Vita FASI VITAProblemi Collegati Concentrazioni basse o fluttuanti di ormoni serici Pubertà-Fase Premestruale Gravidanza-Post Partum Menopausa Contraccettivi Fecondazione Assistita Aborto Terapia Ormonale Sosti. Gravi. Multi. Developmental Life Events-Stress-Trauma Ambiente Familiare Temperamento Cambiamenti Ormonali Predisposizione Genetica Pathways Depressione

17 Gender Differences in The Rates of Exposure to Stressful Life Events and Sensitivity to Their Depressogenic Effects Stressful Life Events Assault Divorce or separation Financial problems Housing problems Illness Job loss Legal problems Loss of confidant Marital problems Robbery Work problems Proximal network event: Problems in getting alone Crisis Death Illness Distal network event: Problems in getting alone Death Illness Kendler KS, et al., 2001

18 Gender Differences in The Rates of Exposure to Stressful Life Events and Sensitivity to Their Depressogenic Effects Conclusion Women reported more interpersonal whereas Men reported more legal and work -related stressful life events. Most life event categories influenced the risk for major depression similarly in the two sexes The greater prevalence of major depression in women versus men is due neither to differences in the rates of reported stressful life events nor to differential sensitivity to their pathogenic effect. Kendler KS, et al., 2001

19 Job loss, Legal problems, Robbery Work problems Housing problems, Loss of confidant, Problems getting along with and crises involving individuals in their proximal network Illness of an individual in their distal network No or inconsistent gender difference: financial or marital problems, illness, illness of individual in in ones proximal network, and problems getting along with and death of an individual in ones distal network Kendler KS, et al., 2001 Male preponderant:Female preponderant: Gender and the Frequency of Stressful Life Events

20 Gender and Sensitivity to Depressogenic Effect of Stressful Life Events divorce or separation work problem problems getting along with and death of an individual in their proximal network No or inconsistent gender difference across samples, no consistent and significant gender differences were seen in the sensitivity to the remaining 15 event categories Kendler KS, et al., 2001 Male-sensitive: Female-sensitive:

21 PREVALENCE OF MD IN WOMEN Genetic Loading Vulnerability/Exposure to Stressful Life Events HPG Axis Neuromodulators Life Cycle in Women PubertyMenopause Modulation Of The Neuroendocrine System by Fluctuating Gonadal Hormones Psychological Reproductive Adolescence, Sexuality, Maternity, Lifestyle, Empty-nest syndrome

22 Longitudinal View of Depressive Illnesses Across Womens Lives Menarche Premenstruum Pregnancy Postpartum Menopause

23 Depression as a function of reproductive related transitions in women Premestrual syndrome Premestrual dysphoric disorder Depression in pregnancy Postpartun blues Postpartum depression Postpartum psychosis Perimenopausal depression Luteal phase of the menstrual cycle Antepartum months First 2 postpartum weeks First postpartum month (up to first 3 pp. month) First postpartum month, especially first 2 pp. weeks 5-7 years prior to menopause Condition Reproductive Transition

24 POSTPARTUM DEPRESSION

25 Depression as a function of reproductive related transitions in women Premestrual syndrome Premestrual dysphoric disorder Depression in pregnancy Postpartun blues Postpartum depression Postpartum psychosis Perimenopausal depression Up to 80% of naturally menstruating women 3%-8% of naturally menstruating women No altered risks for MD. 20% of pregnant women may have minor depressive symptoms 50%-80% of postpartum women 10%-22% of postpartum women 0.1 % of postpartum women exact frequency unknown due to sources of inconsistency across studies (i.e.definition of menopause status) Condition Frequency

26 Postpartum Depression: what its not Postpartum depression has been used as a catchall phrase for many disorders, but its important to differentiate it from other postpartum disorders: Maternity Blues Postpartum panic disorder Postpartum obsessive-compulsive disorder Postpartum bipolar II disorder Postpartum posttraumatic stress disorder Postpartum psychosis (Beck, Cheryl Tatano DNSc, CNM, FAAN, American Journal of Nursing, 2006; 106 (5) 40-50)

27 Postpartum Depression: what it is Depressed Mood or Loss of Interest or Pleasure with 5 or more of the following symptoms for at least two week: 1) insomnia or hypersomnia, 2) psychomotor agitation or retardation, 3) fatigue, 4) changes in appetite, 5) feelings of worthlessness or guilt, 6) decreased concentration and suicidality. Although the DSM-IV-TR states that the depressive episode begins within four weeks of birth, many clinicians and researchers agree that this description is too limiting, as its thought that postpartum depression can occur up to a year after childbirth. Postpartum Depression is a major depressive disorder. It strikes about 1 in 10 women.

28 Premenstrual Dysphoric Disorder (PMDD) Mood symptoms during past oral contraceptive use A past history of depression Mood symptoms during the first 2-4 days postpartum Bloch M et al. J Affect Disord. 2005; 88 (1): RISK FACTORS Associated With The Development of Postpartum Mood Disorders Were found to be significant risk factors for postpartum mood disorders:

29 Prenatal depression Low self-esteem Difficulties with child care Prenatal anxiety A high stress level A low level of social support Poor marital relationship Two recent metaanalyses have identified significant risk factors for Postpartum Depression Beck, Cheryl Tatano DNSc, CNM, FAAN, American Journal of Nursing, 2006 A history of depression Difficult infant temperament Maternity blues Single marital status Low socioeconomic status Unplanned or unwanted pregnancy

30 POST PARTUM DEPRESSION PMDD Mood Symptoms During Past Oral Contraceptive Use A History of Depression Low a low level of social support-socioeconomic status Single marital status-Poor marital relationship Maternity blues Unplanned or unwanted pregnancy Multiple Birth Cesarean Surgery Assisted Conception

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32 Population projection of US adults with lifetime experience of depressive disorder by age and sex from year 2005 to 2050 (III). By year 2050, approximately 46 million US adults aged 18 years Or older will be diagnosed with a depressive disorder. The increase will be more pronounced in adults aged 65 or older. Prevention, detection, and treatment of depressive disorders might attenuate the magnitude of this estimate. Heo M,, Murphy CF ET AL.Int J Geriatr Psychiatry May 23. [Epub ahead of print] CONCLUSIONS

33 ? 296.xx Disturbo Depressivo Maggiore. 2x Episodio Singolo.3x Ricorrente Disturbo Distimico 311 Disturbo Depressivo NAS Classificazione dei Disturbi dellUmore secondo il DSM-IV TR Il problema della diagnosi : Esiste una Depressione dellanziano ?

34 LA PRESENTAZIONE CLINICA DELLA DEPRESSIONE NELLANZIANO Most common clinical features 1. Una restrizione di competenze e abilità sociali, in seguito ad una crescente multi-morbidità, isolamento sociale, solitudine, perdita del partner e dei parenti, nelle sindromi depressive reattive (Müller-Spahn et al, Gerontology 1994) 2. Diffuse e mutevoli lamentele somatiche, ansia e agitazione psicomotoria nelle sindromi depressive endogene (Müller- Spahn et al, Gerontology 1994) 3. Comorbidità con disturbi dansia : disturbo di panico, fobie specifiche, fobia sociale (Lenze et al., Am J Psychiatry 2000)

35 LA PRESENTAZIONE CLINICA DELLA DEPRESSIONE NELLANZIANO Most common clinical features 4)Hopelessness (Joiner et al, J Affect Disorder 2007) : sintomi prodromici 4)Disforia e disturbi dellappetito: sintomi prodromici (Berger et al, Am J Psychiatry 1998) 6) Più lenta risposta agli antidepressivi (Mandelli et al, Psychiatry Res 2007)

36 PSEUDODEMENZA DEPRESSIVA vs ALZHEIMER DATI ANAMNESTICI Evoluzione lenta e progressiva Evoluzione lenta e progressiva Nessuna storia significativa di Nessuna storia significativa diDepressione Evoluzione piuttosto rapida Evoluzione piuttosto rapida Pregressi episodi di tipo Pregressi episodi di tipodepressivo Alzheimer Disease Pseudodemenza Depressiva


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