Download Diagnosis and Management of Depression

Diagnosis and Management of
Depression & Anxiety
Dr. Saima Iqbal
DEPRESSION
• 30-50% of cases of depression are not
detected
• GPs fail to diagnose up to half of their patients
with depressive illness
• Depression often accompanied by and masked
by anxiety
DSM-IV Criteria for Depression
• Key features
1. Low mood and/or
2. Decreased interest or pleasure in life
(anhedonia)
At least one key feature for at least 2 weeks
occurring most of the day or nearly every day
DSM-IV Criteria for Depression
• Symptoms
1.
2.
3.
4.
5.
6.
7.
Change in appetite or weight
Insomnia or hypersomnia
Fatigue or loss of energy
Poor concentration
Psychomotor agitation or retardation
Sense of worthlessness or guilt
Recurrent thoughts of death or suicide
At least 5 of the mentioned symptoms along with one
key feature to make a diagnosis of MAJOR
DEPRESSION
• Minor Depression
– Characterized by 3 or 4 symptoms
• Dysthymia
– Same as above but lasting for at least 2 years
ICD-10 Criteria
• Mild
• Moderate
• Severe
Some of the previously mentioned symptoms
along with functional impairment
Drugs causing depression
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β- blockers
Anti-convulsants
Ca+ channel blockers
Corticosteroids
Oral contraceptives
Antipsychotics
Management of Depression
• Major Depression
– Antidepressant
• SSRI (standard dose) OR
• TCA (amitryptaline 75 mg HS and increase to 150 mg
HS)
• Minor Depression
– Antidepressants not useful unless patient has
dysthymia
– Cognitive behavioral therapy
– Problem solving therapy
Management of Depression
• First choice should be an SSRI e.g fluoxetine or
citalopram
• See the patient after 1-2 weeks to look for
side-effects e.g. agitation or akathisia (If
positive consider 2 week course of
benzodiazepines)
• Explain to the patient that improvement will
only be felt after 3 weeks of therapy
• Continue treatment for 6 months then tail off
over 4 weeks
Management of Depression
• Tail off the drug to avoid discontinuation reaction
(dizziness, parasthesia, tremor, anxiety, nausea,
palpitations)
• Discontinuation reactions usually occur within days of
stopping the drug and last for an average of 10 days
• If mild: explain to the patient what is happening and
continue
• If severe:
– Increase dose/frequency of drug
– Change to longer acting drug
– Tail off over a longer period e.g. 3-6 months
Referral to psychiatrist
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High suicide risk
Psychotic depression
Bipolar disorder
Failure or partial response after 2 attempts to
treat
ANXIETY DISORDERS
• Anxiety disorders are more common than
depression and even less frequently
diagnosed
• Major types of anxiety disorders
– Generalized Anxiety Disorder (GAD)
– Phobias
– Panic attacks/panic disorder
– Obsessive-compulsive disorder (OCD)
– Post-traumatic stress disorder (PTSD)
GAD
• Psychological features
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Fearful anticipation
Irritability
Sensitivity to noise
Poor concentration
Worrying thoughts
Insomnia
Nightmares
Depression
Obsessions
• Physical features
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GAD
Dry mouth
Difficulty swallowing
Tremor
Dizziness
Headache
Parasthesia
Tinnitus
Epigastric discomfort
Frequent or loose motions
Constriction or discomfort in chest
Difficulty breathing or hyperventilation
Palpitations/ missed beats
Frequent micturition
Erectile dysfunction
Menstrual disturbances
Rule out any physical condition mimicking the
symptoms of anxiety e.g. thyrotoxicosis or
asthma!!!
Management of a crisis
• Use benzodiazepines for 2-4 weeks
• Avoid long term due to dependance
Long term treatment
• Cognitive behavioral therapy
• An SSRI
– Start with low dose and increase standard dose to
minimize increase in anxiety
– E.g. Paroxetine 5 mg daily for 2 weeks, double the
dose very fortnight until reaching 20 mg daily
– Treat for at least 6 months after response is achieved,
may go upto 1-2 years
– Tail off gradually
Do not lead patients to expect a cure, they are likely
to be disappointed.
Phobias
Same symptoms as GAD but limited to certain
situations
2 main features
• Avoidance
• Anticipatory anxiety
Phobias
• Simple
– Treatment with exposure therapy
– Symptomatic
• Social
– Intense and persistent fear of being scrutinized or
negatively evaluated by others
– Onset usually before 20 yrs
• Agoraphobia
– Onset 20-30 yrs
– Panic attacks brought on by crowds, away from home
or any place from where escape is difficult
Panic disorder
• Intense feeling of apprehension or impending
disaster
• No recognizable trigger
Panic disorder
• Symptoms
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Shortness of breath/ feeling of suffocation
Choking
Palpitations/increased heartbeat
Chest pain or discomfort
Sweating
Dizziness or faintness
Nausea/abdominal pain
Depersonalization
Numbness or tingling sensation
Flushes or chills
Trembling or shaking
Fear of dying
Fear of doing something uncontrolled
Panic disorder
• Panic attack
– 4 or more symptoms occurring in 1 attack
• Panic disorder
– More than 4 attacks in 4 weeks
OR
– 1 attack followed by persistent fear of having
another
Panic disorder
• Management of hyperventilation
– Talking down
– Rebreathing exercise
– Propanolol 10-20 mg stat (do not use in patients
with asthma or heart failure)
Panic disorder
• Management of panic disorder
– Assess symptoms
– SSRIs (paroxetine, citalopram)
– Cognitive behavioral therapy
Post traumatic stress disorder (PTSD)
• Experiencing or witnessing a traumatic event with
1. Intrusive symptoms
• Memories
• Flashbacks
• Nightmares
2. Avoidant behavior
• Numbing of emotions
3. Hyper arousal
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Anxiety
Irritability
Insomnia
Hypervigilance
Poor concentration
Anger
Post traumatic stress disorder (PTSD)
• Check patient for substance abuse
• Assess risk of suicide
Management of PTSD
• Encourage patient to discuss feelings and fears
• Try to decrease feelings of helplessness and
guilt
• SSRIs, TCAs, CBT