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The Practical Management of Depression Dr Frans A Korb Psychiatrist and Clinical Psychologist Private Practice Fourways Intercare Overview : Depression • The Background • The Facts • Some Biology • Making the Diagnosis • Measuring Depression • Management – Pharmaceutical • Management – Other • The Final Word Definition : Depression ‘Mood is a sustained emotional tone perceived along a normal continuum of sad to happy. Mood disorders are characterized by abnormal feelings of depression or euphoria with associated psychotic features in some severe cases. Mood disorders are divided into bipolar and depressive disorders’ Kaplan & Sadock Depression: Impact on Society A Major Cause of Disability Worldwide Rank 1990 2020 (Estimated) 1 Lower respiratory infections Ischemic heart disease 2 3 4 5 Perinatal conditions HIV/AIDS Unipolar major depression Diarrheal diseases Unipolar major depression Road traffic accidents Cerebrovascular disease Chronic obstructive pulmonary disease Murray CJL, Lopez AD, eds. The Global Burden of Disease. Boston: Harvard University Press; 1996. DEPRESSIVE DISORDERS • DSM-IV vs ICD-10 • Major Depressive Disorder • Dysthymic Disorder • Bipolar Disorder • Cyclothymic Disorder Depression – The Facts The Epidemiology of Depression • Approximately 20% of primary care patients present with depressive symptoms.1 • Depression is almost twice as prevalent in females as in males.2 • Nearly two-thirds of MDD patients have multiple episodes. The risk of recurrence progressively increases with each successive episode and decreases as the duration of recovery increases.3 • Prevalence rates for MDD are unrelated to race, (religion),education, income, or civil status.4 1. Zung WW, et al. J Fam Pract. 1993;37:337-344. 2. Kessler RC, et al. J Affect Disord. 1993;29:85-96. 3. Solomon DA, et al. Am J Psychiatry. 2000; 157:229-233. 4. U.S. Agency for Health Care Policy and Research. Depression in Primary Care: Vol. 1. Detection and Diagnosis. Rockville, MD: 1993: 23. Prevalence Rates of Depression in Chronic Medical Disorders General Population 5.8% Chronically Ill 9.4% Hospitalized 33.0% Older Inpatients 36.0% Cancer Outpatients 33.0% Cancer Inpatients 42.0% Stroke 47.0% MI 45.0% Parkinson's Disease 39.0% 0% 10% 20% 30% Adapted from: WPA/PTD Educational Program on Depressive Disorders. Gavard JA, et al. Diabetes Care. 1993;16(8):1167-1178. 40% 50% Gender Demographics1 MDE Hazard Rates by Age and Sex 0.0140 Female Male Hazard Rates 0.0120 0.0100 0.0080 0.0060 0.0040 0.0020 0.0000 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 Age Category 1. Kessler RC, et al. J Affective Disord. 1993;29:85-96. 40-44 45-49 50-54 Depression – Some Biology Neurotransmission Neurotransmission is the process of sending signals from one component of the nervous system to another 5-HT and NA at the Synaptic Level: Healthy vs. Depressed Healthy Depressed 5-HT Reuptake Transporter NA Reuptake Transporter 5-HT NA Theoretical Representation Depression -- Making the Diagnosis What is Depression ? Depressed mood Traurigkeit Depression Slowed thinking Gedankenhemmung Slowed moving Bewegungshemmung Weygandt “Uber die Mischzustande des manisch-depressiven Irreseins” (Munchen, 1899) Depression. It’s not only a state of mind. The emotional and physical symptoms of depression Emotional Symptoms Include: Physical Symptoms Include: Always feeling sad Vague aches and pains Loss of interest or pleasure Headache Worrying Sleep disturbances Anxiety Fatigue Diminished ability to think or concentrate, indecisiveness Vague back pain Excessive or inappropriate guilt Significant change in appetite resulting in weight loss or gain Reference: Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition,Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489. Tired Unmotivated 35 % 35% have low mood, fatigue, low energy, and lack of motivation. (Agitated) Anxious (Retarded) 34% 31% 34% have mild symptoms of fatigue, low energy, and excessive worry, and are easily overwhelmed 31% have primary anxiety complaints Adelphi Neurosis Market Research Study. 1997. A. Gupta 2000 (n=1590). SPECIAL FORMS OF DEPRESSIVE DISORDERS • Psychotic Depression • Somatic Depression • Atypical Depression • Seasonal Depressive Disorder • Rapid-cycling Bipolar Disorder • Secondary Depressive Disorder OTHER FORMS OF DEPRESSIVE DISORDERS • Dysthymia • Postpartum Depression • Recurrent Brief Depression • Mixed Anxiety-Depression Syndrome • Subthreshold Depression Measuring Depression Depression Management -- Pharmaceutical Depression: Current Treatment Patterns • Only about 1/3 of patients with major depression seek care for their depression (1) • Less than 1/2 of patients with major depression are explicitly recognised as being depressed (2,3) • Only about 1/2 of all depressed patients receive some form of therapy for their illness (2,3) • Only about 1/4 of depressed patients receive an adequate dose and duration of antidepressant treatment (4) 1) Shapiro S, et al. Arch Gen Psychiatry. 1984;41:971-78. 2) Wells KB, et al. JAMA. 1989;262(23):3298-3302. 3) Lepine C, et al. Intl Clin Psychopharm. 1997;12:19-29. 4) Katon W, et al. Medical Care. 1992;39(1):67-76. Classes of Antidepressants • Tricyclic and Tetracyclic Antidepressants (TCAs) Imipramine, clomipramine • Monoamine Oxidase Inhibitors (MAOIs + RIMAs) tranylcypromine, moclobemide • Selective Serotonin Reuptake Inhibitors (SSRIs) fluoxetine, citalopram • Selective Noradrenaline Reuptake Inhibitor (NRI) reboxetine • Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs) duloxetine, venlafaxine • Serotonin-2 Antagonist and Reuptake Inhibitors (SARIs) trazodone, nefazodone • Noradrenergic and Specific Serotonergic Antidepressants (NaSSA) mirtazapine • Dopamine and Noradrenalin Reuptake Inhibitors (DNRI) Bupropion AHCPR, 1993 Depression: Treatment Goals Recovery Remission No Depression Recurrence Relapse X X Relapse X Severity Symptoms Response Syndrome Treatment Phases Acute 6-12 weeks Time Reprinted with permission from Kupfer, 1991 WPA/PTD Educational Program on Depressive Disorders Continuation Maintenance 4-9 months 1 or more years Switching Strategies Pharmacological Strategies for Treatment-Resistant Depression (TRD) Optimization (monotherapy) Increase the dose or duration, or alter the timing of the primary antidepressant. Substitution (switching) Stop first medication, start next one as monotherapy. New drug can be within or across class. Augmentation Add a second drug (adjunct) that is not an antidepressant to the antidepressant that has not produced and adequate response. Combination Two antidepressants used together, typically for synergistic mechanisms. Depression Management -- Other Patient Programmes www.sadag.co.za mySupport Programme www.bouncingback.co.za Depression – The Final Word Social-Endocrine-Psychological Interactions Depression: Treatment Goals Treatment Reduce/Remove Signs, Symptoms Restore Role/ Function Minimise Relapse/ Recurrence Risk AHCPR Guidelines: Depression in Primary Care, Vol 2. US Dept. of Health and Human Services; 1993. Depression Is ... • Prevalent worldwide • Common in primary care setting • Often unrecognized, inadequately treated • Associated with high morbidity, mortality, cost • PCP can provide effective treatment [email protected]