Download Depression

DEPRESSION
EPIDEMIOLOGY AND BURDEN

Depression is a highly prevalent condition

About one in a seven will experience depression during
their lifetime

Many people with depression will have a recurrent or
chronic course

Depression is the fourth leading cause of disability
worldwide

Depression results in work absence and loss of
productivity leading to significant economic loss
AETIOLOGY OF DEPRESSION
 Biological
(genetics), psychological (life events),
and social factors (lack of social support) are
involved in the etiology and pathophysiology of
depression
 Stressful
life events and stress reactivity can
modify genetic and biological processes
FACTORS PREDICTING
PROLONGED COURSE OF
DEPRESSIVE EPISODE
•
Severe depression
•
Alcohol and drug abuse
•
Comorbid illness
•
Psychotic features
•
Poor social support
•
Early age of onset
•
Long duration
•
Low levels of functioning prior to depression
CLINICAL FEATURES OF
DEPRESSION
Depressive symptom
Presentation
Sleep
Insomnia or hypersomnia
Interest/pleasure
Decreased (anhedonia)
Guilt
Increased; Irrational thoughts
Energy
Decreased (fatigue)
Concentration
Decreased (indecisive)
Appetite
Decreased or increased
Psychomotor activity
Agitation or retardation
Suicide
Thoughts, plans, attempts
TYPES OF DEPRESSION
Types of depression
Major depressive disorder
Severity of depression
Dysthymia
Moderate
Depressive disorder, not
otherwise specified
Severe
Minor depressive disorder
Premenstrual dysphoric
disorder
Mild
MAJOR DEPRESSIVE DISORDER
Five or more of the following for at least 2 weeks:
1.
Depressed mood
2.
Loss of interest in pleasure
3.
Significant weight loss
4.
Insomnia or hypersomnia
5.
Psychomotor agitation or retardation
6.
Fatigue
7.
Excessive guilt or feelings of worthlessness
8.
Diminished ability to think or concentrate
9.
Recurrent thoughts of death
DYSTHYMIA
Depressed mood for at least 2 years
Two or more of the following:
A.
B.
1.
2.
3.
4.
5.
6.
Poor appetite or overeating
Insomnia or hypresomnia
Low energy or fatigue
Low self esteem
Indecisive or poor concentration
Feelings of hopelessness
MINOR DEPRESSIVE DISORDER

Episodes of at least 2 weeks of depression

Fewer than five items required for major depressive
disorder
RISK FACTORS FOR SUICIDE
EPISODE RELATED
 Current
suicidal plans
 Prior attempts
 Severe depression
 Hopelessness and guilt
 Bipolarity
 Mixed state (with agitation)
 Psychotic features
 Substance abuse
 Serious medical condition
 Anxiety
RISK FACTORS FOR SUICIDE
DEMOGRAPHICS
Male
 Adolescent or elderly
 Early onset of mood disorder
 Family history of suicide
 Adverse childhood experiences
 Adverse life circumstances
 Recent stressor
 Lack of social support

DIFFERENTIAL DIAGNOSIS

Substance induced mood disorder

Bereavement

Mood disorder due to a general medical condition
COMMON DRUGS OF ABUSE
CAUSING DEPRESSION
 Alcohol
 Amphetamines
 Anti-anxiety
drugs
 Cocaine
 Hallucinogens
 Hypnotics
 Inhalants
 Opioids
 Sedatives
DEPRESSION DUE TO GENERAL
MEDICAL CONDITIONS
•
•
•
Diabetes
Cardiovascular disease
Neurological
–
–
–
•
Systemic disorders
–
•
•
Viral and bacterial infections
Endocrine disorders
–
•
CNS infections
Epilepsy
Sleep apnoea
Thyroid disorders
Vitamin deficiencies (B12/Folate; Vitamin C; Niacin; Thiamine)
Others
–
–
AIDS
Cardiopulmonary disease
MANAGEMENT OF DEPRESSION

Phase 1: Acute phase - to achieve full remission of
depressive symptoms

Phase 2: Maintenance phase - to prevent relapse and
recurrence
ACUTE PHASE MANAGEMENT OF
DEPRESSION

8-12 weeks of treatment

Goal: remission of symptoms

Establish therapeutic alliance

Educate patients and relatives

Aid self management

Choose treatment(s)

Manage side effects

Monitor and follow-up
MAINTENANCE PHASE
MANAGEMENT OF DEPRESSION

6-24 months or longer of treatment

Goal: prevention of relapse and recurrence

Educate patients and relatives

Aid self management

Manage side effects

Rehabilitate work and social function

Monitor for recurrence
PHARMACOTHERAPY
RECOMMENDATIONS

Minimum six months treatment after full remission of
symptoms

At least 2 years (for some lifetime)





Severe episodes
Chronic episodes
Comorbidity
Difficult-to-treat episodes
Frequent episodes
PATIENT/FAMILY EDUCATION
 Explain
depression in terms of biochemical basis:
“Depression is an illness, not a weakness”
 Early
diagnosis and treatment is important for
recovery
 Reducing
and stopping medications without
medical advice is wrong
 Monitor
weight; advise exercise and food plans
PATIENT EDUCATION MESSAGES
TREATMENT
 Antidepressants
 Medications
 It
are not addictive
daily, as prescribed
may take 2-3 weeks before any relief is seen
 Mild
time
side effects are common, they get better over
 Medications
should not be stopped without
medical advice
SELECTING AN ANTIDEPRESSANT

The first line medications are selective serotonin reuptake
inhibitors (SSRIs) and serotonin norepinephrine reuptake
inhibitors (SNRIs)

They are preferred over tricyclic antidepressants (TCAs)
SELECTING AN ANTIDEPRESSANT

Efficacy

Side effect profile

Concurrent medication

Comorbidity

Subtype of depression

Simplicity of use

Cost
SSRIS
Mechanism Common
Drug
of action
side effects
Selective
inhibition of
serotonin
reuptake
GI distress,
nausea,
vomiting,
diarrhoea
Headache,
agitation,
sleep
disturbance,
drowsiness,
dry mouth,
sexual side
effects
Daily dose
Escitalopra 5-20 mg
m
Fluoxetine 20-80 mg
Sertraline
50-200 mg
Paroxetine
20-60 mg
Fluvoxamin 100-300 mg
e
TCAS
Mechanism Common
Drug
of action
side effects
Inhibition of
serotonin and
norepinephrin
e reuptake
Dry mouth,
blurred vision,
constipation,
urinary
retention,
confusion
drowsiness,
sedation, weight
gain, nausea,
tremor,
headache,
seizures, sexual
dysfunction
Imipramine
Daily dose
75-300 mg
Amitryptaline 75-300 mg
Cloimipramin 75-300 mg
e
Dothiepin
75-300 mg
Nortrptaline
75-150 mg
OTHER EVIDENCE BASED
THERAPIES FOR DEPRESSION
 Electro
Convulsive therapy (ECT)
 Exercise,
therapy
wake therapy and light
 Psychotherapy

Cognitive Behaviour therapy

Family therapy

Interpersonal psychotherapy
CONCLUSION

Depression a disabling illness

Can be recurrent and chronic

There are cognitive, emotional and physical symptoms of
depression

Suicide in a important risk of depression

Depression can be treated effectively with evidence based
therapies such as antidepressants, ECT and
psychotherapy