Download Depression is a Prevalent Disorder 3

Depression and management
Guidelines
Prof. Dr. Momtaz AbdEl Wahab
Prof. of psychiatry
Cairo University
1
Face the Facts
Depression is a Prevalent
Disorder
2
Epidemiology
3
Epidemiology
• The depression research in European
society (DEPRES) study found that almost
16% of total population had suffered from
depression in their life time. (lepin jp. etal
1979).
• The incidence is almost identical in USA
17%(kessler R.C.etal 1994).
4
Depression is a Prevalent Disorder
121 Million People Suffer From
Depression
ATLAS (WHO 2001)
5
Face the Facts
The Prevalence of
Depression is Rising?!
6
Epidemiology (cont’d)
• The incidence of depression appears
to be increasing, although this may
be explained by an increasing
willingness to report psychological
problems.
7
Anxiety
STRESS
Depression
(DALYS, 2020)
OVERLOAD
Disasters
Globalization
Massive information
Techno stress
Individualization
WARS
Lack of support
Noises
EVERYDAY LIFE
Economic
Recession
Time pressure
Spouces
Pollution
Anticipation
of danger
Boss
Others
Excessive
respondents
8
The Burden of
Depression
9
Face the Facts
Depression is a
Burden
10
The burden of depression
• Disability associated with depression
is reportedly greater than that for
chronic illnesses such as arthritis,
back pain, diabetes gastrointestinal
disease, hypertension and long
diseases.
11
Leading causes of disability worldwide
in years of life lived with disability
Cause
Unipolor major depression
Iron deficiency anemia
Falls
Alcohol use
%
10.07
4.7
4.6
3.3
Chronic obstructive pulmonary
disease
Bipolar disorder
Congenital anomalies
3.1
Osteoarthritis
Schizophrenia
2.8
2.6
3
2.9
12
World Bank Reports
Year
Anxiety Depression
2000 is the
world
4th greatest health problem
2020 will be the
2nd greatest health problem
causing disability
13
Face the Facts
Depression in an Expensive
Disorder
14
The burden of depression
• The disorder tends to become recurrent or
chronic with time.
• 50% of the life of depressed patients life
span will be clouded by the illness.
• The depressed patient is often isolated,
the dysfunction has repercussion on:
- family member
- friends
- colleagues
Their relationships frequently being
15
shattered
The burden of depression
• Behavioral changes are common:
- increased drinking
- initiation drug abuse
• Unfortunately, the patients
themselves are often not aware of
being clinically depressed, and thus
will not actively seek help or
treatment.
16
The burden of depression
• Several studies has shown higher
mortality risk in depressed
individual:
-suicidal risk is high 15%-19%
-cardiovascular deaths
• Depressive symptoms seem to be
risk factors for mortality in
pulmonary disorders and stroke.
17
The burden of depression
• Depressed patient is less likely to sustain
a demanding job or career or to achieve
his or her potential.
• If the depression arises during the
formative years, an in evitable
consequence is diminished performance
at school, college, or educational training
with life long consequences.
18
Economic implications for society
• Reduced and lost productivity
- absenteeism
- wasted training
• The increased strain and demands
on health services.
• The increased direct cost of
treatment, particularly caused by
hospital admissions.
19
COST
Direct
Indirect
• Recurrence
• Disability in work
• Treatment
• Poor social function
• Hospitalization
• Associated behavioral
problems
• Increase self destructive
behaviors
20
Face the Facts
Depression is a Recurrent
Disorder
21
Face the Facts
• Depression is too painful to be
ignored.
• Depression is unrecognized!!
• Depression has many faces.
22
20% of those with major depression
have symptoms that persist beyond
2 years
Keller et al., (1992) & Scot & Dicky (2003), B. J. Psychiat.
23
The need for treatment
• Depression continue to be a silent
epidemic because so few people with
depression receive treatment.
• 50% of depressed patients had not
consulted physician.
• Of those who had 70% had been given no
medication for depression.
• Less than 10% of those with major
depressive disorder had been prescribed
an antidepressant.
24
Face the Facts
Depression is an
Under-recognized Disorder
 Stigma.
 Masked depression.
 Comorbid medical illness.
 Time constraints.
 Inadequate medical education.
25
The need for treatment
• In addition, when antidepressants
are prescript, dosage and duration of
treatment are often mostly
inadequate to achieve a response or
maintain remission.
26
Reasons for under recognition/ under
treatment of depression
•
•
•
•
•
Provider
Inadequate training.
Depression not a real disorder
(preoccupied with organicity ).
Time- consuming to evaluate (failure to
elicit symptoms).
Restricted access to treatment options.
Failure to refer from G.P. when indicated.
27
Reasons for under recognition/
under treatment of depression
Patient
•
•
•
•
•
•
Stigma.
Ignorance.
Effect of the symptoms.
Poor compliance.
Poor insurance coverage.
Presentation: somatization.
28
Why is it important to recognize
depression?
•
•
•
•
High costs.
Suicide and other mortality.
Risk factor for co morbidity.
Very treatable.
29
Diagnosis and Symptoms
30
Many Faces of Depression
Depressive symptoms

Background
Somatic symptoms

Foreground
31
Face the Facts
Depression is recorded in up to 30% of
patients seen by other specialties
• Oncology
• Dermatology
• GIT
• CNS
• C.V.S.
• Others
32
Presenting Complaints in
Primary Care Practice
CONTROL (N=
Gastrointestinal
DEPRESSED (N=
Central
Nervous
Genitourinary
Cardiorespiratory
)
General
(Widmer & Cadoret,331978)
Depression in Primary Care
%
%
Not recognized
Recognized
34
Okasha, 2003
“ICEBERG” PHENOMENON
Depressed
patients seen by
psychiatrists
Depressed patients
seen in primary care
practice
35
Many Faces of Depression
Why there is a Tendency for
depression to manifest itself in the
somatization sphere
36
Only about ½ of patients with MD are explicitly
recognized as being depressed.
Only about ½ of all depressed patients
receive some form of therapy for their illness
(Lepine et al 1997)
Only about ¼ of depressed patient receive an
adequate dose and duration of AD treatment
(Katon et al 1992)
37
• The understanding of the underlying
neurobiology and neurochemical dysfunction
in depression is an essential issue for the
proper management
38
Neuobiology of
Depression
HPA
Axis
Neuro
circuittary
Immune
system
Neuropeptides
Dysfunction
in
Neurotransmitters
5HT, NE, DA
Neurohormones
Circadian rhythm
Others
39
Khalia M (2005): Metabolism Clinical & experimental
54 Suppl(1).; 24-27
Linking Neurotransmitters and
neurocirciuts with Symptoms of Depression
Dysfunction
in
Neuro
circuits
Neurotransmitters
5HT, NE, DA
40
Neuroanatomical & Neurochemical
Basis of Symptoms of Depression
EMOTIONAL
SOMATIC
COGNITIVE
Loss of
pleasure,
interest &
motivation
Sadness &
suicide
Fatigue
loss of
energy
Sleep
appetite
Libido
etc.
Attention
Concentration
Problem solving





Dorsolateral
PFC
Ventromedial
PFC
DA
NE
5HT
Nucleus
accumbens &
hypothalamus
Dorso-lateral
PFC
DA
5HT
NE
DA
5HT
NE
DA
DA (D1)
Ach.
5HT
NE
GABA
Histamine
41
Malhi GS, et al., (2005): Acta Psychiatr. Scand.; 111:94-105
Functional Roles of Brain Monoamines
Norepinephrine
Serotonin
Anxiety
Irritability
Energy
Interest
Social function
Memory
Motivation
Attention
Impulse
Control
Mood,
Emotion,
Cognitive
function
Sex & appetite
Aggression
Drive
Reward
Executive function
Dopamine
42
Modified from Healy & McMonagle. J Psychopharmacol 1997; 11 (suppl 4): S25-S31.
Scheme of Diagnosis
Depression
Course
Single
Recurrent
Severity
Mild
Moderate
Psychosis
Severe
Symptoms
With
Typical
Without
Atypical
43
Symptoms
Pattern of Symptoms:
• Typical.
• Atypical.
• With melancholic.
44
Diagnostic Process
1) Common Presentations
Usually the patient presents either of the
following symptoms:
1- Multiple Somatic complaints.
2- Lack of Concentration and/or forgetfullness.
3- Increased fatigability.
45
2) Signs suggesting a depressive disorder:
1. The patient has multiple and excessive complaints,
involving more than one system in the body.
2. The complaints are vague and ill defined and
cannot be categorized as one identifiably disease.
3. The patient is easily predictable, giving yes as an
answer to any question.
4. On physical examination, there are not enough
signs to explain the symptoms described by the
patient.
5. Results of investigations are always within the
normal ranges.
46
3) Diagnostic Criteria
A. At least one on the following symptoms has to
prevail for at least two weeks.
1- Depressed mood for most of the day and
almost every day.
2- loss of interest or pleasure in doing the
activities that were normally pleasurable.
47
B) At least four of the following symptoms:
1- change in appetite.
2- Sleep Disturbance.
3- Psychomotor disturbance.
4- Increased fatigability or loss of energy.
5- Feeling of worthlessness as well as excessive
inappropriate guilt.
6- Diminished ability to think and concentrate.
7- a state of indecisiveness.
8- Recurrent thoughts of death.
9- Pessimistic views of the future.
48
C) The symptoms lead to significant distress or
impairment in social, occupational or other
important functional areas.
49
Atypical symptoms include:
1-vegetative symptoms of reserved
polarity as:-hypersomnia
-increased appetite
-weight gain.
2-marked mood reactivity.
3-sensitivity to emotional rejection.
50
severity
1.
•
•
2.
•
•
Mild episode characterized by:
Minimum diagnostic requirements
Minor function impairment
Moderate episode
The symptoms present exceed the
bare diagnostic requirements
Greater degrees of functional
impairment
51
Severe Episode
• Presence of several symptoms
beyond the minimum required to
make diagnoses.
• Marked interference with social
and/or occupational functioning.
52
Severe Episode
In
extreme
unavailable
cases,individuals
to
function
might
be
socially,
occupationally, un-able to feed and clothe
themselves, or to maintain minimal personal
hygiene.
•Presence of suicidal ideation and attempt.
•Presence of psychotic symptoms.
•Presence of catatonic symptoms.
•Presence melancholic symptoms.
53
Psychosis
•
Psychosis is considered when
there is:
1. Delusions
2. Hallucinations
3. Catatonic symptoms
54
Catatonic symptoms
Characterized by at least two of the following:
1. Motor immobility (catalepsy or stupor)
2. Extreme agitation
3. Extreme negativism
4. Posturing
5. Stereotyped movements, mannerisms or
grimacing
6. Echolalia or echopraxia
55
Melancholic Symptoms
1- Loss of pleasure in all, or almost all activities.
2-Lack of reactivity
(anhedonia).
to
pleasurable
stimuli
3- Distinct quality of depressed mood.
4- Diurnal variation (depression regularly worse in
the morning).
56
Melancholic Symptoms
5-Early morning awakening.
6- Marked psychomotor retardation or agitation.
7- Significant anorexia or weight loss.
8- Excessive or inappropriate guilt.
57
OTHER FORMS OF
DEPRESSIVE DISORDERS
• Dysthymia
• Postpartum depression
• Recurrent brief depression
• Mixed anxiety-depression syndrome
• Sub-threshold depression
• Premenstrual Dysphoric Disorder
• Post menopausal Depression
58
SPECIAL FORMS OF
DEPRESSIVE DISORDERS
• Psychotic depression
• Somatic depression
• Atypical depression
59
SPECIAL FORMS OF
DEPRESSIVE DISORDERS (cont’d)
• Seasonal depressive disorder.
• Rapid-cycling
bipolar
disorder,
depressive episode.
• Secondary depressive disorder.
60
Depression Due to a General
Medical Conditions
1- Depression due to general medical condition

Endocrine disorders
Cushing's disease).

Diseases of CNS, CVS, chest disease.

Collagen disease ( Rheumatoid arthritis, SLE)

Chronic infections ( hepatitis, T.B.)

Neurological diseases ( Parkinsonism, CVS)

Neoplasm( cancer lung, cancer GIT).
(D.M.,
2- Depression secondary to other
drugs (steroids, & reserpine).
hypothyroidism,
nonpsycho-active
61
Prevalence of Depressive Disorders
In Different Patient Populations*
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
pu
la
tio
n
ill
G
en
er
al
po
ni
ca
lly
d
Ch
ro
pi
ta
liz
e
ts
in
p
Ho
s
at
ie
n
ts
G
er
ia
tri
c
tp
a
tie
n
ts
Ca
nc
er
er
nc
Ca
ou
in
p
at
ie
n
ke
I
M
St
ro
di
se
as
e
%
's
on
in
s
rk
Pa
%
Prevalence
*There is a range of percentages depending on the study.
62
Depression Adversely Affects
Medical Diseases
Play a role in:
Exacerbation.
Delayed recovery.
Prolonged course.
Poor outcome.
Prolonged
Hospitalization.
63
MYTH

Depression is obvious
and easily recognized
and expressed by the
patient
REALITY

Depression disorders
are overlapping,
hardly expressed by
the patient and
constitute a major
problem in symptom
exaggeration
64
MYTH

Depression is
Secondary to GMD
activity
Treatment of the medical
disorder will relief
Depression.
REALITY

DEPRESSION
REQUIRES TREATMENT
intervention and do not
remit with relieve of
symptoms
65
DIAGNOSIS: THE CLINICAL
INTERVIEW
• Listen
• Facilitate
– “Go on.”
– “What else?”
• Demonstrate concern
• Summarize
• Try to put the patient at ease
• Begin with open-ended questions
• Probe for symptoms, e.g.
– “Any trouble with your nerves?”
– “How have you been sleeping?”
– “What do you do to enjoy yourself?”
66
M
I
N
I
MINI INTERNATIONAL NEUROPSYCHIATRIC
INTERVIEW
• The MINI is a brief structured interview for the major Axis I
psychiatric diorders in DSM-IV & ICD-10.
• Compared to the SCID-P (structured interview developed
by the WHO ), the MINI has acceptably high validation
and reliability scores, but can be administered in a much
shorter time.
67
‫‪Depressed mood or loss of‬‬
‫?‪feeling‬‬
‫• هل أحسست باألكتئاب أو أن حالتك النفسية سيئة فى معظم‬
‫أوقات اليوم و بصورة متكررة خالل األسبوعين الماضيين؟‬
‫• خالل األسبوعين الماضيين هل كنت أقل اهتماما أو أقل‬
‫استمتاعا باألشياء التى كنت تتمتع بها أغلب الوقت ؟‬
‫‪68‬‬
‫‪Markedly diminished interest or‬‬
‫?‪pleasure or enjoyment or anhedonia‬‬
‫‪ .1‬هل عمرك حسيت إن ملكش نفس في أى حاجة أومش قادر‬
‫تتمتع بأي شيء حلو كنت قبل كده بـتتمتع به (مثال الفرجة‬
‫على التلفزيون ‪ ،‬قراءة الجريدة أو زيارة حد‪ ،‬أو هواية كنت‬
‫بتمارسها ‪ ،‬أو الخروج مع األصحاب ‪ ،‬أو حتى أكلة حلوة)‬
‫‪ .2‬هل استمر هذا االحساس معظم اليوم تقريبا فى معظم أيام‬
‫األسبوع ولمدة ال تقل عن أسبوعين كاملين؟‬
‫‪69‬‬
‫اذا كانت األجابة على أى من السؤالين ”بنعم“‬
‫استمر فى االجابة على األسئلة التالية‪:‬‬
‫‪ .3‬عندما شعرت أنك مكتئب أو مهموم أو حزين‬
‫خالل األسبوعين الماضيين‪:‬‬
‫‪70‬‬
‫‪(.3‬أ)‬
‫‪Weight loss – gain; decreased /‬‬
‫?‪increased appetite‬‬
‫• هل الحظت إنك خسيت جامد أو زاد وزنك زيادة‬
‫ملحوظة؟‬
‫• هل الحظت أن شهيتك لألكل زادت أو نقصت عن‬
‫الطبيعي و كان ذلك لمعظم اليوم تقريبا معظم أيام‬
‫األسبوع‪.‬‬
‫‪71‬‬
‫‪(.3‬ب)‬
‫‪Insomnia or hypersomnia, sleep‬‬
‫?‪disturbances‬‬
‫• هل الحظت أن هناك صعوبة في النوم (صعوبة في‬
‫الدخول إلي النوم أو تصحى كذا مرة بالليل أو تقوم‬
‫بدري قوي عن الطبيعي)؟‬
‫• هل الحظت أنك بتنام أكثر بكثير من الطبيعي بتاعك‬
‫معظم األيام في خالل هذه الفترة؟‬
‫‪72‬‬
‫‪(.3‬ج)‬
‫‪Psychomotor agitation or‬‬
‫‪retardation‬‬
‫• هل الحظت انك متململ ومش قادر تقعد في مكان واحد‬
‫معظم األيام في هذه الفترة؟‬
‫• هل الحظت ان عندك بطئ في الحركة و الكالم معظم‬
‫األيام في هذه الفترة؟‬
‫‪73‬‬
‫‪(.3‬د)‬
‫‪Fatigue or loss of energy‬‬
‫• هل حسيت أنك مرهق وتعبان على طول و مش قادر‬
‫على عمل أى حاجة وماعندكش طاقة وال حيوية معظم‬
‫األيام في هذه الفترة؟‬
‫‪74‬‬
‫‪(.3‬ه)‬
‫‪Feeling of worthlessness or excessive or‬‬
‫‪inappropriate guilt, self blame and reproach,‬‬
‫• هل كان بيجيلك إحساس داخلي إن روحك المعنوية منخفضة أو‬
‫انك أقل من الناس وانك مالكش قيمة في معظم األيام في هذه‬
‫الفترة؟‬
‫• هل كان بيجيلك إحساس داخلي بالذنب و تأنيب الضمير بدون‬
‫سبب واضح في معظم األيام في هذه الفترة؟‬
‫• هل بتميل إنك تلوم نفسك على حاجات انت عملتها أو فكرت‬
‫فيها؟‬
‫‪75‬‬
‫‪(.3‬و)‬
‫‪and‬‬
‫‪Diminished‬‬
‫‪ability‬‬
‫‪to‬‬
‫‪think‬‬
‫‪concentrate, indecisiveness‬‬
‫• هل كنت في هذه الفترة غير قادر على التركيز والتفكير‬
‫بوضوح أو أنك كثير التردد؟‬
‫‪76‬‬
‫‪(.3‬ز)‬
‫‪Thoughts‬‬
‫‪of‬‬
‫‪death,‬‬
‫‪catastrophe,‬‬
‫‪suicidal ideation, attempt, plan or self‬‬
‫‪harm‬‬
‫• هل حسيت أن الحياة ما تستهلش الواحد يعيش فيها أو أنه مش‬
‫حايفرق معاك انك ما تصحاش تانى يوم الصبح؟‬
‫• هل فكرت في هذه الفترة أن تؤذى نفسك بأي طريقة ؟‬
‫• هل كنت في هذه الفترة بتفكر كثير في الموت أو تتمناه أو‬
‫بيجيلك أفكار عن االنتحار ؟‬
‫• هل أنت ميال انك تقعد تفكر فى مصايب ممكن تحصل زى الموت‬
‫أو خراب البيوت أو أي كارثة؟‬
‫‪77‬‬
‫‪Diagnosis:‬‬
‫اذا حصلت على ‪ 5‬اجابات أو أكثر ”بنعم“ على األسئلة من‬
‫‪.3‬أ الى ‪.3‬ز‬
‫اذا فالمريض يعانى من‬
‫نوبة اكتئاب حالية‬
‫‪Current Depressive Episode‬‬
‫‪78‬‬
‫‪Check for Recurrent Episodes‬‬
‫‪( .4‬أ) خالل سنوات حياتك الماضية هل مررت بفترات‬
‫أخرى (مدتها أسبوعين أو أكثر) أحسست خاللها‬
‫باالكتئاب أو أنك غير مهتم بمعظم األشياء أو عانيت‬
‫خاللها بنفس األعراض السالف ذكرها؟‬
‫‪(.4‬ب) هل مرت عليك مدة ال تقل عن شهرين بدون اكتئاب‬
‫أو احساس بعدم االهتمام فى فترة ما بين نوبتين‬
‫لالكتئاب؟‬
‫‪79‬‬
‫نوبة اكتئاب متكررة‬
‫‪Not due to a substance or a‬‬
‫‪general medical condition‬‬
‫• هل قبل هذه األعراض كنت مريض بأي مرض أو‬
‫اتعرضت على دكاترة تانيين؟‬
‫• هل أخذت أي أدوية أو عالجات قبل هذه األعراض ؟‬
‫• هل قبل هذه األعراض أخذت مكيفات أو كحوليات؟‬
‫‪80‬‬
Questions
1- The DSM-IV classification of mood
disorders encompasses all of the
following except
1.
2.
3.
4.
5.
Bipolar disorders
Dysthymia
Posttraumatic stress disorder
Cyclothemia
Major depression
2- which of the following statements is
true of dysthymic disorders?
1. Symptoms less intense and invasive
than major depression.
2. Symptoms have both characteristics
of both depressive and manic
syndromes.
3. Hypomanic features must be of at
least two years duration.
4. It’s a variety of bipolar disorder.
5. None of the above is true.
3- Which of the following statements
isn’t true of bipolar disorders?
1. It occurs in 0.4% to 1.2% of the adult
population
2. It has a familial pattern associated
with it
3. The first episode usually occurs
between 20 & 40 years of age
4. Depression occurs more frequently
than mania
5. Forty percent of patient with typical
bipolar disorder respond to lithium.
4- The concept of uncomplicated
bereavement includes all of the
following except
1. It isn’t a mental disorder under DSMIV
2. It isn’t categorized as a major
depressive episode under DSM-IV
3. It’s a normal reaction
4. It’s of varied duration among different
cultural groups
5. It’s an exacerbation of a previous
mental disorder
5- All of the following are
characteristics of melancholia except
1. Loss of interest or pleasure in all or
almost all activities.
2. Lack of reactivity to pleasure stimuli
3. Depression regularly worse in
morning
4. Endogenous origin
5. Consistent early morning awakening
6- an individual whose
symptomatology fulfills the criteria
for dysthymic disorder , but who
have intermittent periods of normal
mood which last more than a few
months is BEST classified as having
1. Depressive disorder, otherwise not
classified.
2. Dysthymic disorder
3. Cyclothemic disorder
4. Major depressive disorder
5. None of the above
7- All of the following are symptoms of
a major depression except :
1.
2.
3.
4.
disorientation to time .
Delusions involving concern of AIDS.
Failure to care to personnel hygiene.
Overemphasis on the bad things of
life.
5. Thought blocking .
8- The following statements are true
regarding atypical depression.
1. Increase in food intake and sleeping is
common.
2. Mood is unreactive.
3. Personality issues are prominent.
4. Delusions are systematized.
9- sleep disturbance in depression.
1.
2.
3.
4.
Is most typically early awaking.
Not important sign.
Nightmare aren’t common.
Sleep is refreshing.
10- treatment with SSRIs :
1. Not associated with sleep disturbance.
2. Not associated with nausea and
vomiting.
3. Can result in orgasmic impotence.
4. Complicated dosing regimen.