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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.