Download depression?

Session
Plan
Outline of Discussion

What is the site of depression on the map of MD?
{Classification of Mental Disorders}ICD-10-PHC & DSM-4

Why Depression?

Size of the problem
(Morbidity &Burden of Illness…)

When do you consider (suspect) depression?

How do you diagnose a depression?

Clinical presentation and D.D

Tips and Pitfalls in diagnosis of depression?

Management Plan

Risk assessment

Preventive issues related to Mental Disorders.
Patient problem
A 34-years-old lady presented to your office, she told
you that she has been ‘way down’ for the past 4
months and has not felt much like doing anything.
She had a previous “nervous breakdown” when she
was 22 years old. She was working as business
executive until 4 months ago but has found it
impossible not only to work but also to do anything
else.
She had worked at her present position for
approximately 18 months but was finding work an
increasing stress.
She was working approximately 75 hours/week and
having to deal with daily difficulties and conflicts.
She is currently on long term sick leave.
She expresses her current situation best by saying, “I have
no joy left in life”. I do not enjoy doing anything, I have
not any interest in any of my previous activities.
Her other symptoms include sleep approximately 14
hours/day, almost continual feelings of guilt and
hopeless, a state of having almost no energy “ all of the
time” decreased concentrating ability, no appetite and
loss of weight + 12 Kg, and being unable to “ move
around “ or get anything done.
Her marriage is described as “excellent” her husband is very
supportive. She does admit, however, to a significant
decrease in sexual interest and activity. Her family history
is significant for alcoholism in her father. She is on no
drug and has no allergies.
Her physical examination is completely normal in all
systems.
1.What is the most likely diagnosis in this patient?
Select the best answer to the following questions
A) Adjustment disorder secondary to work stress
B) Generalized anxiety disorder
C) Major depressive disorder
D) Organic affective disorder
E) Dysthymia
2.Which of the following types of psychotherapy are most
commonly used in the illness above?
1.
2.
3.
4.
5.
Psychoanalytic psychotherapy
Behavioral Psychotherapy
Cognitive psychotherapy
Supportive psychotherapy
All of above
3. The aims or goals of the psychotherapy for this
condition include which of the following?
A. Providing a therapeutic rationale or explanation
for the patient's symptoms
B. Providing ongoing education regarding the
illness, prognosis and treatment
C. Guiding the patient with respect to
interpersonal relationships, work, and major
life adjustments
D. Helping to bolster the patient’s morale
E. All of the above.
4.What is the pharmacologic agent of choice in the
disorder described?
A) a selective serotonin reuptake inhibitor (SSRI)
B) a tricyclic antidepressant
C) a non selective MOA inhibitor
D) a selective MAO inhibitor
E) Lithium carbonate
Patient problem
A
41-years old male presents with 3-year
history of a “depressed mood”. He states that
he feels “depressed most of the time”,
although there are periods when he feels
better than others.
He feels chronically tired, has some difficulty
concentrating at work, and has found it
difficult to remain productive and efficient as
representative of a major company. He has
had no other symptoms. His health is
otherwise good. He is on no medications.
1) What is the most likely diagnosis?
Adjustment disorder
Dysthymic disorder
Major depressive disorder
Organic affective disorder
None of the above
2) What is the treatment of choice for this patient?
A tricyclic antidepressant
Serotinin reuptake inhibitor
Supportive and/or cognitive psychotherapy
A and C
B and C
Answer of the second problem
1.C
2.E
3.E
4.A
Answer of the second problem
1.B
2.E
WHEN DO YOU CONSIDER DEPRESSION ?
How ?
Screening Tool
The common cold” of MD and
The “ butter” of psychiatry,
Dr.Nadia Mabrouk
A.Prof.FM
Outline of Discussion

What is the site of depression on the map of MD?
{Classification of Mental Disorders}ICD-10-PHC & DSM-4

Why Depression?

Size of the problem
(Morbidity &Burden of Illness…)

When do you consider (suspect) depression?

How do you diagnose a depression?

Clinical presentation and D.D

Tips and Pitfalls in diagnosis of depression?

Management Plan

Risk assessment

Preventive issues related to Mental Disorders.
World Health Organization's classification of mental disorders in primary health
care
================================================================================================
Organic D
Mood, stress related, and anxiety D
physiological D
FOO
Dementia
F32
Depression
F50 Eating disorders
F05
Delirium
F40
Phobic disorder
F51
Sleep D
F41.0
Panic disorder
F52
Sexual D
Psychoactive substance use
F41.1
Generalized anxiety
F41.2
M ixed anxiety and depression
FI
Alcohol use disorder
F43
Adjustment disorde
F11
Drug use disorder
F44
Dissociative disorder
F17.1
Tobacco use
F45
F48
Unexplained somatic complaints
Neurasthenia
==============================================================================================
Psychotic disorders
F20
Chronic psychotic disorder
F23
Acute psychotic disorder
F31
Bipolar disorder,
Development disorde rs
F 70
M ental retardation
Disorders of childhood
F90
Hyperkinetic disorder
F91
Conduct disorder
F98
Enuresis
================================================================================================
WHY DEPRESSION
SIZE OF THE PROBLEM
 In multi-center worldwide study conducted in
15 countries in general health care screened +
26422 persons using 12-item GHQ, About 25%
had well defined mental disorders, further 9%
had subthreshold conditions (WHO,1993).
 The most common disorders were depression
(10%), general anxiety disorder (8%), and
harmful use of alcohol (3%)(WHO,1993).
WHY DEPRESSION
SIZE OF THE PROBLEM

Lifetime prevalence of major depression
(7-12%) among men in epidemiological
studies.

Lifetime prevalence of major depression
(20-25%)
among
women
in
epidemiological studies.

The prevalence of major depression in PHC
settings (5-10% )
WHY DEPRESSION
SIZE OF THE PROBLEM
Studies demonstrate that one out of seven
adult persons in the USA have a mood disorder
during a single year, 7% in Brazil, almost 10%
in Germany and 4.2% in Turkey.
In the USA, 5% of children aged 9-17 were
found to have depression, a disorder thought
to spare youth and adolescents. Ignoring this
reality can result in suicide.
WHY DEPRESSION
SIZE OF THHE PROBLEM IN EGYPT
 Prevalence rate of the psychiatric disorders among patients
attending primary health care (Ismailia Governorate) using GHQ
was 33.5% (Awad, 1985). [The commonest mental disorder was
depression (61.5%)].
 Prevalence of psychiatric disorders in rural Egypt was found to
be as high as 42.4% in leading community study (El- Akabawy
et al.1982).
 The prevalence rate of the psychiatric disorders among general
population in rural Menia using GHQ was 31.7% (Soliman et al.
1997).[Prevalence rate of depression was 22.8 %& anxiety was
18.6 %& somatization was 18.5%].
WHY DEPRESSION
SIZE OF THHE PROBLEM IN EGYPT
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009 65
National Survey of Prevalence of Mental Disorders in Egypt:
preliminary survey
M. Ghanem,1 M. Gadallah,2 F.A. Meky,2 S. Mourad3 and G. El-Kholy1
WHY DEPRESSION
SIZE OF THHE PROBLEM IN EGYPT

This study was conducted in 2003 as an initial step for the
National Survey of Prevalence of Mental Disorders in Egypt.
We conducted a door-to-door household survey of 14 640
adults aged 18–64 years in 5 regions in Egypt including
Ismailia.

Overall prevalence was estimated at 16.93% of the studied
adult population.

The main problems were mood disorders, 6.43%, anxiety
disorders, 4.75%, and multiple disorders, 4.72%.
WHY DEPRESSION
BURDEN OF ILLNESS
CONSEQUENCES OF DEPRESSION
The 1993 world development report of the World
Bank estimated that mental health problems
represent 8% of the global burden of disease. Its
toll is greater than that of TB, cancer or heart
disease (World Bank Report, 1993).
It is also responsible for the greatest proportion of
burden attributable to non fatal health outcomes,
accounting for almost 12% of total years lived
with disability
WHY DEPRESSION
BURDEN OF ILLNESS
CONSEQUENCES OF DEPRESSION
 The total annual cost estimate (both direct and
indirect costs) is $43.7 billion in the United States
 Stigma and QOL
 Mortality rate
WHEN DO YOU CONSIDER DEPRESSION
Factors which render a person more vulnerable to get
depression… examples are:
Positive family history
Loss of mother before the age of 11Y
Cancer in the family
Women with 3 or more children under 14 years of age
and living alone, with no close relationship
Post- natal period.
Bereavement, especially widows with no family
Poor diet
Social isolation.
Significant life events
Death of a loved one- child, spouse (husband or wife) or
a relative.
Divorce or separation
Loss of a job.
Breakdown of a relationship.
Moving house.
Adverse financial conditions.
Be biased toward diagnosis of depression
WHEN DO YOU CONSIDER DEPRESSION
Difficult consultations
Frequent attendants
Patients with chronic painful physical illness- cancer, diabetes.
Patients with unexplained physical symptoms
Patients with decreased libido
Factors that predispose to a new episode of depression or the
past history of:
A long history of depression
Manic depressive illness
Sever attack of depression
More than one episode that lasted for more than 2 weeks.
Be biased toward diagnosis of depression
How DO YOU Screen for Depression
??????????????????????????????????
DIAGNOSTIC CRITERIA OF DEPRESSION
DSM4
Criteria
A- Five symptoms from the mentioned list, but depressed
mood or anhedonia are required. The symptoms must
have been present all of the day, nearly every day for 2
weeks.
1.Depressed mood (sadness)
2.Anhedonia (lack of interest or pleasure in almost all activities)
3.loss of energy (fatigue)
4. Reduced self esteem or guilt
5.Reduced concentration or trouble making decisions
6. Recurrent thoughts of death or suicidal ideas
7. Psychomotor retardation or agitation (observed by others)
8. Sleep disorder (insomnia or hypersomnia)
9. Appetite loss, weight loss & appetite gain, weight gain
DIAGNOSTIC CRITERIA OF DEPRESSION
Criteria
B- The symptoms cause clinically significant distress or
impairment in functioning (social, occupational or
other areas)
C- The symptoms are not due to Physical or organic
factors or illness
D-The symptoms are not better explained by
bereavement (although this can be complicated by
depression).
DIAGNOSTIC CRITERIA OF DEPRESSION
A mnemonic for major depressive disorder is as follow:
====================================
SIG: EMCAPS
1)
S = Sleep (hypersomnia)
2)
I = Interest (lack of interest in life in general)
3)
G = Guilt or hopelessness
4)
E = Energy or fatigue
5)
M =Mood (depressed, sad)
6)
C =Concentration (lack of)
7)
A =Appetite (increased or decreased, weight loss or gain)
8)
P =Psychomotor (retardation or agitation)
9)
S =Suicidal ideation
====================================
Major depressive disorder can be diagnosed based on
presence of 5 out of 9 including no. (2 or 5).
SEVERITY OF DEPRESSION
Each depressive episode could be graded according to
the severity into mild, moderate or severe :
====================================
Mild to Moderate Depression

Threshold number (5) of symptoms with minimal
functional impairment.

Marked symptoms and impairment of function.
Severe depression
All or nearly all symptoms and marked functional
impairment in all areas of life
====================================
CLASSIFICATION OF DEPRESSION
Primary Depression
Unipolar



Major depressive disorder (single episode)
Recurrent depressive disorder (recurrent episodes)
Dysthyma
Bipolar


Bipolar affective disorder
Cyclothyma
Others


Seasonal affective disorder
Mixed anxiety and depressive disorder
Secondary Depression
DIAFFERENTIAL D. OF DEPRESSION
1-Medical Mimics of Depression-Masquerades-2ry





Endocrine Disorders
 Hypo/hyperthyroidism
 Cushing's syndrome
Collagen V D (SLE/RA..)
Hematological D (Anemia)
Infectious D (Hepatitis;Influenza;HIV)
Neurological D





Dementia
Parkinsonism
CVS
Neoplastic D
Nutritional/Metabolic D



Hypokalemia/ hyponatremia
Uremia
Malnutrition particularly in elderly
2- Drug Induced Depression
3- Other Mental D
DIAFFERENTIAL D. OF DEPRESSION
2-Drug induced Depression







Cardiovascular agents
 Beta B; CCB,Aldomet; Reserpine; Clonidine;
Digitalis;Dyslipedemic D (Pravcastatin)
Respiratory Agents
 Corticosteroids; Antituberculous D (INH)
GIT Agents
 H2 antagonist
Neurological Agents
 Carbamezapine
 Phenytoin
 PhenobarbitalParkinsonism
Gynecological Preparation
 Contraceptives
Cancer Treatment
Psychotropic Agents
 Benzodiazepines
 Antipsychotic
 Barbiturates
DIAFFERENTIAL D. OF DEPRESSION
3-Drug induced Depression
Acute Psychotic Disorders
Consider
acute
psychotic
disorders
if
hallucinations
(hearing voices, seeing visions) or delusions (strange or
unusual beliefs) are present.
Bipolar Disorder
Consider bipolar disorder if history of manic episode
(excitement, elevated
mood, and rapid
speech)
is
present.
Alcohol Use Disorders
Consider alcohol use disorders if there is a history of
alcohol use.
Dementia particularly among elderly
HOW DO YOU DIAGNOSE DEPRESSION ?
Interview and history taking
Physical Examination
Mental state Examination
If we go through this process, it will
lead to early and definite diagnosis of
depression
CLINICAL PRESENTATION OF DEPRESSION
WHO-ICD-10
Presenting Complaints

The patient may be presented initially with one or
more physical symptoms (fatigue, pain).

Further inquiry will reveal depression or loss of
interest.

Sometimes the depression presents as irritability.
CLINICAL PRESENTATION OF DEPRESSION
WHO-ICD-10
Diagnostic Features





Low OR sad mood
Loss of interest OR pleasure
Associated symptoms are frequently present:
 Disturbed sleep
 Guilt or low self-worth
 Fatigue or loss of energy
 Poor concentration
 Disturbed appetite
 Suicidal thoughts or acts
Movements and speech may be slowed, but may also appear
agitated.
Symptoms of anxiety or nervousness are frequently also
present.
Non pharmacological
Therapy
Pharmacological
(Biological) therapy
Others,(ECT)
MANAGEMENT OF PATIENT WITH
DEPRESSION
Presenting the diagnosis
Tell the patient
that he/she has
Depression
Do not tell the
patient that
he/she has
Depression
How??
Exercise
Presenting the diagnosis
A 45- year old- single woman came to see her family
physician complaining of abdominal pain and nervous
exhaustion. In the interview her physician noted that her
affect was flat and that she spoke with long latencies. She
was having trouble sleeping, frequent awaking after 4
hours, sleep with perspiration, heart palpitations, and
obsessive worries about her job.
She had assumed a new job 4 months earlier as manager
of a hospital clinic that was converting to a new data
management system. After the physician ascertained that
the patient was not suicidal, She summarized the patient
concerns and presented her diagnosis in the following
dialogue:
Presenting the diagnosis
Doctor: It is obvious that last few weeks have been like torture
for you.
It sounds like you carry a lot of responsibilities (including the
working in the clinic that is depending on you). Let’s talk about
what I think is going on and then I, d like to get your ideas
about that.
You have said that you are finding less energy during the
day and that you awaken frequently at night, sometimes
only getting a few hours, sleep. You tend to judge your self
harshly, and lately you feel guilty that you are not
accomplishing more. You have lost interest in things you
used to enjoy, and lately all you can think about is your
job. You are finding it harder to concentrate, and making
simple decisions. Did I leave out anything?
Presenting the diagnosis
Doctor: All these symptoms indicate to me that you are
suffering from depression. This is an illness that affects our
nervous system in way that robs us of our usual ability to
enjoy the pleasure of life and to have confidence in our
abilities. Your depressed mood is leading you to view
yourself through a distorted lens that filters out all
recognition of your competencies and abilities.
[Pause to check patient’s response. After head nod from
the patient, The doctor proceeds as follow]
Any person is prone to that, fortunately, depression is very
treatable illness and there are some very effective
strategies you and I can work on together. This may be
hard for you to believe right now, because of hopeless
feeling that accompanies depression, but I’m quite
confident that within a few weeks you will be feeling much
better about yourself and about life.
Presenting the diagnosis
Important Tips
 Summarize the symptoms
 May you add a couple of additional symptoms not mentioned
by the patient to check their presence or absence.
 Express the common existing of such illness to relieve the
associated stigma.
 May you use some diagrams to explain the illness
 Emphasize on that depression is curable illness.
 Discuss the available resources that may help in overcoming
the stresses that precipitated the occurrence of depression.
MANAGEMENT OF PATIENT WITH
DEPRESSION
A) Essential Information for Patient and Family
1) Depression is common and effective treatments are
available.
2) Depression is not weakness or laziness; patients are
trying their hardest to cope.
B) Specific Counseling to Patient and Family
(1)Ask about risk of suicide.
 Has the patient thought of death or dying?
 Does the patient have a specific suicide plan?
 Can the patient be sure not to act on suicidal ideas?
 Close supervision by family or friends may be needed.
How ?
SUICIDE RISK ASSESSMENT
(SAD PERSONS INDEX)
==========================================
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Sex
Age
Depression
Psychiatric history
Excessive drug use
Rationality loss
Separated
Organized plan
No support
Sickness
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Male
<20 >45 years
Major Depression
Previous attempts
Substance abuser
Psychotic, s depression
Loss of spouse
Determined suicide plan
No back up ; isolated
Chronic illness
1
1
2
1
1
2
1
2
1
1
Score > 7 means high suicide risk
==========================================
MANAGEMENT OF PATIENT WITH
DEPRESSION
B) Specific Counseling to Patient and Family
(2) plan short-term activities, which give enjoyment
or build confidence
(3)
Resist pessimism and self-criticism.
Do not act on pessimistic ideas (e.g. ending
marriage, leaving job).
Do not concentrate on negative or guilty thoughts.
(4)Identify current life problems or social stresses.
 Focus on small, specific steps that patient might take
towards reducing or better managing these problem.
 Avoid major decisions or life change.
How do you Help
your Pt ?
MANAGEMENT OF PATIENT WITH
DEPRESSION
SPEAK Approach to help Pt to overcome Depression
Schedule
Pleasurable Activities
Exercise
Assertiveness (sharing other feeling)
Kind thoughts about your self (replace
negative ones with positive)
MANAGEMENT OF PATIENT WITH
DEPRESSION
B) Specific Counseling to Patient and Family
(5)If physical symptoms are present, discuss link
between physical symptoms and mood
(6) After improvement, discuss signs of relapse,
plan with patient action to be taken if signs of
relapse occur.
MANAGEMENT OF PATIENT WITH
DEPRESSION
C) Pharmacological treatment
(1)Consider antidepressant drugs if sad mood or
loss of interest is prominent for at least 2
weeks and 4 or more of associated symptoms
are present:
In severe cases consider medication at the
first visit.
If good response to one drug in the past uses
that again.
If older or medically ill, use newer medication
with fewer side effects.
If anxious or unable to sleep, use more
sedating drug.
MANAGEMENT OF PATIENT WITH
DEPRESSION
C) Pharmacological treatment
(2)Build up to effective dose (e.g. imipramine starting at
25 to 50 mg each night and Increasing to 100- 150 mg
by I0 days) - lower doses if older or medically ill.
(3) Explain how medications should be used:
 Medication must be taken every day,
 Improvement will build over 2-3 weeks.
 Mild side effects may occur and usually fade in 7-10
days.

Check with the doctor before stopping medication.
(4) Continue antidepressant at least 3 months after
symptoms Improve.
MANAGEMENT OF PATIENT WITH
DEPRESSION
C) Pharmacological treatment
Antidepressant Agents
Table 1. A guide to the selection of commonly used antidepressants table
Generic Name
Brand Name
Common Dosage Range
Common Adverse Effects
Imipramine
Tofranil
50-300 ing daily
Sedation, dry mouth, orthostatic
hypotension, prolonged QT interval
Desipramine
Norpramin
50-300 ing daily
Similar to but less than
irmpramine; commonly used in the elderly
Nortriptyline
Pamelor, Aventyl
50-150 mg daily
Fewer adverse effects compared with
imipramine, commonly used in elderly
Fluxetine
Prozac
20-40 mg daily
Tremulousness, gastrointestinal upset,
difficulty sleeping, sexual Dysfunction
Paraxetine
Paxil
2-50 ing daily
Same as fluoxetine, usually more sedating
Citaloprain
Celexa
20-60 ing daily
Less sexual dysfunction; loose stools are
common
Nefazodone
Serzone
150-300 ing twice daily
None consistently (no effect on sexual
dysfunction)
Ventafaxine
Effexor, Effexor XR
75-225 ing daily (SR) or in divided
doses
Sedation, hypertension
Trazodone
Desyrel
50-500 ing daily or in divided doses
Sedation (useful at low doses for sleep),
orthostatic Hypotension
Bupropion
Welibutrin,
Wellbutrin
SR
300-450 ing divided three times daily
or twice daily (SR form)
Agitation, lowered seizure Threshold
Tricyclic antidepressants
Selective serotonin reuptake
inhibitors
Serotonin-norepinephrine reuptake
inhibitors
Other
WHEN DO YOU REFER ??

Uncertainty about diagnosis

Inpatient care obviously necessary

Severe depression

Inability to cope at home

Psychotically depressed( with delusion or hallucinations)

Substantial suicide risk

Failure of response to routine antidepressant therapy

Associated physical and psychiatric disorders


Children with apparent major depression
Difficult problem in elderly where diagnosis
including dementia is doubtful.
Is it possible to prevent depression in
your practice population?
Task
Screening for Depression