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DEPRESSION DR.DUAA HIASAT
Objectives
• Definition of depression .
• Signs & symptoms of depression according to DSM & ICD.
• Approach to depressed patient.
• Management.
• Assess suicidal risk in depressed patient.
General principles
• Mood: is a description of ones internal state of being.
• Affect: the external display of ones mood.
• Variation of mood is normal.
• Mood disorders occurs when a patient's mood is not controllable and causes impairment in daily living activities.
Diagnostic & statistical manual of International classification Mental disorders of diseases & related health problem ( American psychiatric association) ( WHO )
Epidemiology of depression • Depression is highly prevalent among general population.
• Mood disorders will be experienced by 9.5% of adults, MDD
by 6.7% and BPD BY 2.6%.
• Female more than males.
• More if positive family history.
• Mean age of onset Late 20s .
• Depression is important in primary care.
• Depression is usually under-recognised.
Etiologies & theories
• GENETICS
First degree relatives have three folds risk.
Etiologies & theories
• PSYCHOSOCIAL FACTORS
1-recurrent stressful life events.
2-loss of parents before the age of 10.
3-living alone/lack of social support.
4-chronic pain.
5-alcohol & substance abuse.
6-medications.
7-vascular….post stroke, CAD.
Monoamine hypothesis
• Most antidepressant medications increase the levels of
one or more of the monoamines—the neurotransmitters
serotonin, norepinephrine and dopamine—in the
synaptic cleft between neurons in the brain. Some
medications affect the monoamine receptors directly.
Depression- definition
Clinical syndrome of emotional, cognitive and physical symptoms associated with significant impacts on quality of life.
DSM-4 : Depressive disorder
Common depressive disorders in primary care
Major depression disorder ( MDD ).
Dysthymia.
Bipolar disorder.
Seasonal patterns.
Mood disorder secondary to a general medical condition.
Diagnostic criteria S&S
DSM4 DSM5 ICD10
Depressed mood . Y Y
anhydonia . Y Y
weight . Y Y
sleep . Y Y
psychomotor . Y Y
fatigue . Y Y
guilty . Y Y
Cognitive problem . Y Y
Thoughts of death . Y Y
Self confidence/ esteem
problem
Y
Level of severity Sub-threshold depressive symptoms
Fewer than 4 symptoms of depression
Mild depression
Few symptoms in excess of the 4,required to make diagnosis,&
symptoms result in only minor functional impairment
Moderate depression
Symptoms & functional impairment s are BW mild & sever.
Sever depression
Most symptoms , & the symptoms markedly interferes with functioning.
This can occurs with or without psychotic symptoms
Major depression disorder ( MDD ).
• Chronic and relapsing, ccc by periods of exacerbation and
remission.
• Periods of remission can last years, but stressful events
can bring out relapse.
• Can cause significant impairment.
• May occure in adolescents or latter in life.
Dysthymia
• This is also known as chronic persistent depressive
disorder.
• More resistant to ttt .
• Less likely to relieved by periods of remission or by
antidepressant.
Seasonal pattern
• Depression symptoms during winter months in regions that experience a marked decrease in ambient light during the winter.
• Symptoms of hypersomnia, hyperphagia, & psychomotor slowing .
• Hx of remission during summer months is helpful in the diagnosis.
• Respond to high-intensity light therapy.
Screening
• Because of high rates of unrecognized depression
caseses.
• USPSTF recommends screening adults for depression
when staff-assissted depression care supports are
available for accurate diagnosis, effective ttt, & follow-up.
• USPSTF AGAINST screening…..
Screening
• Conflicting recommendations, indicates the importance of
proper monitoring & follow-up as mainstay of depression
management.
Screening for…
• People at risk of depression:
1. Hx of depression. 2. Significant physical illness causing disability. 3. Substance abuse. 4. Other mental health problems. 5. Complaints that involve multiple organ systems or are
physiologically unrelated. 6. Sleep disturbance. 7. Frequent ER visits. 8. Patient who express thoughts or emotions that are inappropriate
to the context.
Approach to depression
History taking.
Physical examination.
Lab investigation.
Differential Diagnosis.
Treatment.
History taking
• Profile
Age, gender, marital status.
• Chief complaint
- SIGECAPS.
- Duration.
S:sleep disturbance.
I: decreased interest.
G: guilt or worthlessness.
E: decreased energy or fatigue.
C: concentration poor.
A: appetite or weight.
P: psychomotor agitation.
S: suicidal ideation.
2 weeks
History taking
Details about the symptom.
Other depression symptoms ( SIGECAP)
1:Mood----depressed
2:Sleep----increased or decreased
3:Interest----decreased
4:Guilt or worthlessness
5:Energy----decreased or fatigued
6:Concentration poor
7:Appetite or weight----increase or decrease
8:Psychomotor activity----increase or decrease
9:Suicidal ideation.
History taking
Diurnal variation.
Etiology of the problem ( emotional , financial, loss of job,
home environment)
Post partum period.
First time or recurrent.
Seasonal pattern.
Other somatic symptoms( headache, back pain, SOB).
Other psychiatric illnesses.
History taking
• Social history
Loss of parents, living alone.
• Medical history
Chronic debilitating illnesses…. DM,HTN,Cancer,chronic
pain.
• Family history
Three fold increase risk of depression.
Drug history
Physical examination
• General look
General self neglection, no eye contact, self cutting
marks….
• Mental status examination.
• Vital signs.
• Thyroid examination.
Psychological MDD, Dysthymia, bipolar
disorder, seasonal pattern,
post partum blue
Endocrinopatheis Hypothyroidism, DM.
Drug Mentioned……
Hematologic Anemia
cardiopulmonary HF, strock, post MI
CTD Polymyalgia rheumatica, RA.
Sleep diseases Sleep apnea
Renal Renal failure
PSYCHIATRIC MANAGEMENT
• Psychiatric management consists of interventions &
activities that should be initiated & provided during all
phases of treatment.
PSYCHIATRIC MANAGEMENT
1. Discussion & shared agreement.
2. Acute phase treatment ( psychotherapy,
pharmacotherapy, ECT).
3. Evaluate response.
4. Continuation phase.
5. Maintenance phase. Monitoring to patient.
6. Discontinuation phase.
Cont…..
• A strong trusting relation and therapeutic alliance btw ptn &dr,
as this facilitates the stages of treatment.
• Evaluate the safety of the patient by assessing the suicidal risk,
if he demonstrates suicidal or homicidal ideation, close
monitoring or hospitalization is needed.
Factors Increasing the Risk of Suicide in
Depressed Patients 1. Increased age (70 years in men, 60 in women)
2. Gender (women make more attempts; men are more often
successful)
3. Poor social support
4. Lack of marital support and absence of children
5. Chronic physical illness or chronic pain
6. Alcoholism or substance abuse
7. History of prior attempts
8. Specific plan or explicit communication about intent
9. Family history of successful suicide
Discussion & shared agreement
1. Consider the patient’s clinical condition including severity of symptoms or general medical conditions, level of functioning impairment.
2. Availability of supporting system.
3. Reliable feed-back process.
4. Enhance the treatment adherence by assessing the barrier to treatment, discuss concerns about ttt or side effect.
5. Consider the patient’s preferences when modify or develop the treatment plane.
6. Encourage self-management activities.
7. Provide continuous education to the patient & family.
Acute phase treatment
• Aim to induce remission of MDD & achieve a full return to
patient baseline level of functioning.
• Remission: at least 3weeks of absence of both
depressed mood & inhedonia & no more than three
remaining symptoms of MDD.
TREATMENT MODALITIES
1. Pharmacotherapy.
2. Psychotherapy.
3. Electroconvulsive therapy.
Contiu….
• Selection depends on :
Severity of the symptoms.
Co-occuring disorders or psychosocial stressors.
Biological , environmental factor at the current episode.
Patient preference.
Prior treatment experience.
Pharmacotherapy
• Selective serotonin reuptake inhibitors(SSRI).
• Tricyclic antidepressants(TCA).
• Monoamine oxidase inhibitors(MAOI).
• Reversible inhibition of MAO-A(RIMA).
• Serotonin & norepinephrine reuptake inhibitors(SNRI).
• Serotonin &dopamine reuptake inhibitors(SDRI).
• Other cyclics (nefazodone).
Pharmacotherapy
• Points to consider when selecting a medication include:
• History of good response to previous use.
• Successful use of an agent in a close relative (use by a parent or sibling may enhance compliance).
• Presence of chronic pain or severe sleep disturbance (if so , consider using a TCA).
• Coexisting medical conditions (e.g., avoid TCAs in patients with known cardiac conduction disturbances).
• Hypersomnia (if so, consider an SSRI).
• Cost.
• Adverse effects and potential for drug interactions.
• Patient preference.
Tricyclic antidepressants
• Mode of Action : Block norepinephrine and serotonin
Reuptake
• Side Effects: Anticholinergic effects : dry mouth, blurry vision,
acute glaucoma, constipation, urinary retention
• Noradrenergic effects: tremors, tachycardia, sweating, insomnia,
erectile and ejaculation problems
• α-1 adrenergic effects: orthostatic hypotension
• Antihistamine effects: sedation, weight gain
• CNS: sedation, stimulation, decease seizure threshold
• CVS: increased HR, conduction delay
SSRI
• Block serotonin reuptake only
• Side effects: Fewer than TCA, therefore increased compliance
• CNS: restlessness, tremor, insomnia, headache, drowsiness
• GI: N/V, diarrhea, abdominal cramps, weight loss
• Sexual dysfunction: impotence, anorgasmia
• CVS: increased HR, conduction delay, serotonin syndrome,
EPS,
• SIADH
SSRI
• SSRIs inhibit P450 enzymes, therefore will affect levels of
drugs metabolized by P450 system
• Serotonin syndrome with MAOI: nausea, diarrhea, palpitations,
hyperthermia, chills, neuromuscular irritability, altered
consciousness
Psychotherapy
• Interpersonal therapy.
a brief, psychotherapy that centers on resolving
interpersonal problems and symptomatic recovery. It is an
empirically supported treatment (EST) that follows a highly
structured and time-limited approach and is intended to be
completed within 12–16 weeks.
Psychotherapy
• Cognitive behavioral therapy
is a short-term, goal-oriented psychotherapy treatment that
takes a hands-on, practical approach to problem-solving.
Its goal is to change patterns of thinking or behaviour that
are behind people's difficulties, and so change the way they
feel.
Psychotherapy
• Problem-solving therapy
is a cognitive – behavioral intervention geared to improve
an individual's ability to cope with stressful life experiences.
The underlying assumption of this approach is that
symptoms of psychopathology can often be understood as
the negative consequences of ineffective or maladaptive
coping.
Electroconvulsive treatment
• Depression refractory to adequate pharmacological trial, High
suicide risk, Malnutrition secondary to food refusal.
• 70-90% of patient will show improvement.
• Some precautions to be considered.
• Treatment are usually given 2-3 times /week, an acute course of
ECT typically consists of 6-12 ttt, until symptoms have remitted
or reached plateau.
Evaluate response
• Sufficient duration, frequency & dose.
• You need 4-8 weeks needed before it can be concluded the response to medication.
• Modify the dose if no symptomatic improvement after 1 month.
• If inadequate response maximize ttt.
change to other ttt.
Augment & combine ttt.
Continuous phase
• To reduce the high risk of relapse, continue the
medication for 4-9 months at the same dose used in acute
phase to achieve remission.
• MONITOR for signs of relapse.
Maintenance phase
• To prevent recurrence, recurrence is common occure in about 20% of cases within 6 months of remission.
• Risk factors for recurrence :
1. Persistence of sub threshold depressive symptoms.
2. Prior hx of multiple episode of MDD.
3. Sever initial episode.
4. Early age of onset.
• The same previous effective treatment.
• MONITOR for signs of depression.
Discontinuation of treatment
• Stable patient .
• Taper the medication over at least several weeks:
to allow for the detection of recurring symptoms.
Tapering minimize discontinuation syndrome, esp. with
paroxetine & venlafaxine.
• Continue to MONITOR the patient.
