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. La Depressione : definizione La depressione come fenomeno appare di non facile definizione, in quanto legata indissolubilmente al concetto di umore. L’umore è una dimensione complessa della vita psichica dell’uomo, nella quale confluiscono aspetti emozionali, affettivo/sentimentali, cognitivi, temporali, motivazionali e motori che, se così si può dire, “colora di sé” tutta la vita dell’individuo, costituendo una sorta di griglia percettiva ed elaborativa con cui si dà significato alla realtà. (Vella, Siracusano1994) La Depressione : definizione Esiste una linea di continuità che collega la depressione sia alla tristezza, esperienza comune e fisiologica, 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 essere riconosciuta nella loro pervasività, nell’interessare psiche e soma allo stesso modo, nella loro fissità, nel non essere più modificabili dalle situazioni esterne, tristi o liete, nell’intensità del dolore, che tende a congelare vissuti psichici e somatici in un unico blocco privo di spinta evolutiva. 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 l’uccisione di persone coinvolte nei loro sistemi deliranti 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. 2008 May 23. [Epub ahead of print] Population projection of US adults with lifetime experience of depressive disorder by age and sex from year 2005 to 2050 (II). From year 2005-2050, 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 (3.8-8.2, a 117% increase???) than in the young population aged < 65 years (30.1-37.7, a 25% increase). Heo M,, Murphy CF ET AL.Int J Geriatr Psychiatry. 2008 May 23. [Epub ahead of print] 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 l’uccisione di persone coinvolte nei loro sistemi deliranti 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) Prevalenza della depressione (National Comorbidity Survey) Percentuale di Casi 30 25 20 Maschi Femmine 15 10 5 0 ia z an f In 24 15 34 25 44 35 54 45 Classi di Et (anni) 64 55 Gender Differences in Prevalence of Major Depression Women: 1.5-2.5 X rate relative to men during ages 15-54 Kessler et al (1993) Journal of Affective Disorders 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 selfimage, temperament and early sexuality (Stattin and Magnusson) New, hormonally driven needs for affiliation, difficulties with the transition to adolescence negative life events (Cyranowski) Genetic loading negative life events (Silberg, Pickles, Rutter) History of MD, traumatic experiences, genetic factors, temperament (Kendler) Girls who lack healthy parental attachmentsanxious or inhibited temperament failed to develop good coping skills (Cyranowski) 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 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): 5308-13 DEPRESSIONE NELLA DONNA Fasi Vita Fasi FASI vita VITA Problemi Collegati Concentrazioni basse o fluttuanti di ormoni serici IPOTESI TEORICHE Developmental Life Events-Stress-Trauma Ambiente Familiare Contraccettivi Fecondazione Assistita Aborto Pubertà-Fase Premestruale Terapia Gravidanza-Post Partum Ormonale Sosti. Menopausa Gravi. Multi. Temperamento Cambiamenti Ormonali Predisposizione Genetica Pathways Depressione 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 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 Gender and the Frequency of Stressful Life Events Male preponderant: Female preponderant: • Housing problems, • Job loss, • Loss of confidant, • Legal problems, • Problems getting along with and crises • Robbery involving individuals in their proximal • Work problems network • Illness of an individual in their distal network No or inconsistent gender difference: financial or marital problems, illness, illness of individual in in one’s proximal network, and problems getting along with and death of an individual in one’s distal network Kendler KS, et al., 2001 Gender and Sensitivity to Depressogenic Effect of Stressful Life Events Male-sensitive: • • divorce or separation work problem Female-sensitive: • 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 PREVALENCE OF MD IN WOMEN Vulnerability/Exposure to Stressful Life Events Genetic Loading Life Cycle in Women HPG Axis Reproductive Modulation Of The Neuroendocrine System by Fluctuating Gonadal Hormones Neuromodulators Psychological Puberty Adolescence, Sexuality, Maternity, Lifestyle, “Empty-nest syndrome” Menopause Longitudinal View of Depressive Illnesses Across Women’s Lives Menarche Premenstruum Pregnancy Postpartum Menopause Depression as a function of reproductive related transitions in women Condition Reproductive Transition Premestrual syndrome Luteal phase of the menstrual cycle Premestrual dysphoric disorder Luteal phase of the menstrual cycle Depression in pregnancy Postpartun “blues” Antepartum months First 2 postpartum weeks Postpartum depression First postpartum month (up to first 3 pp. month) Postpartum psychosis First postpartum month, especially first 2 pp. weeks Perimenopausal depression 5-7 years prior to menopause POSTPARTUM DEPRESSION Depression as a function of reproductive related transitions in women Condition Frequency Premestrual syndrome Up to 80% of naturally menstruating women Premestrual dysphoric disorder 3%-8% of naturally menstruating women Depression in pregnancy Postpartun “blues” No altered risks for MD. 20% of pregnant women may have minor depressive symptoms 50%-80% of postpartum women Postpartum depression 10%-22% of postpartum women Postpartum psychosis 0.1 % of postpartum women Perimenopausal depression exact frequency unknown due to sources of inconsistency across studies (i.e.definition of menopause status) Postpartum Depression: what it’s not Postpartum depression has been used as a catchall phrase for many disorders, but it’s 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) Postpartum Depression: what it is Postpartum Depression is a major depressive disorder. It strikes about 1 in 10 women. 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 it’s thought that postpartum depression can occur up to a year after childbirth. RISK FACTORS Associated With The Development of Postpartum Mood Disorders Were found to be significant risk factors for postpartum mood disorders: 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): 9-18. Two recent metaanalyses have identified significant risk factors for Postpartum Depression Prenatal depression A history of depression Low self-esteem Difficulties with child care Difficult infant temperament Prenatal anxiety A high stress level Single marital status A low level of social support Low socioeconomic status Poor marital relationship Unplanned or unwanted pregnancy Maternity blues Beck, Cheryl Tatano DNSc, CNM, FAAN, American Journal of Nursing, 2006 A History of Depression Mood Symptoms During Past Oral Contraceptive Use Low a low level of social support-socioeconomic status PMDD Single marital status-Poor marital relationship Unplanned or unwanted pregnancy Multiple Birth Cesarean Surgery Assisted Conception Maternity blues POST PARTUM DEPRESSION Population projection of US adults with lifetime experience of depressive disorder by age and sex from year 2005 to 2050 (III). CONCLUSIONS 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. 2008 May 23. [Epub ahead of print] Il problema della diagnosi : Esiste una “Depressione dell’anziano” ? Classificazione dei Disturbi dell’Umore secondo il DSM-IV TR 296.xx Disturbo Depressivo Maggiore .2x Episodio Singolo .3x Ricorrente 300.4 Disturbo Distimico 311 Disturbo Depressivo NAS LA PRESENTAZIONE CLINICA DELLA DEPRESSIONE NELL’ANZIANO 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 ” (MüllerSpahn et al, Gerontology 1994) 3. Comorbidità con disturbi d’ansia : disturbo di panico, fobie specifiche, fobia sociale (Lenze et al., Am J Psychiatry 2000) LA PRESENTAZIONE CLINICA DELLA DEPRESSIONE NELL’ANZIANO Most common clinical features 4) Hopelessness (Joiner et al, J Affect Disorder 2007) 4) Disforia e disturbi dell’appetito: sintomi prodromici (Berger et al, Am J Psychiatry 1998) 6) Più lenta risposta agli antidepressivi (Mandelli et al, Psychiatry Res 2007) PSEUDODEMENZA DEPRESSIVA vs ALZHEIMER DATI ANAMNESTICI Alzheimer Disease Pseudodemenza Depressiva Evoluzione lenta e progressiva Evoluzione piuttosto rapida Nessuna storia significativa di Depressione Pregressi episodi di tipo depressivo