Download Moderate depressive episode

Malaysian
CPG on the
Management
of Major
Depressive
Disorder
Major depressive disorder:
prevalence

Lifetime prevalence from community
surveys: 5% to 17% (Kessler 1994, AHCPR
1993)

Six- to 12-month prevalence estimates:
2-11%, weighted mean 6% (Andrade et al.
2003; Robins and Regier 1991)
Burden of disease

By year 2020 major depression projected to
be 2nd largest contributor to global burden of
disease, after heart disease (Murray & Lopez, 1997)
 By 2030, the leading cause of DALYs
worldwide is projected to be unipolar
depressive disorders, followed by ischaemic
heart disease and road traffic accidents (WHO
2008)

Risk for suicide associated with depressive
disorders elevated 12- to 20-fold compared to
general population (Harris & Barraclough 1997)

Malaysian Burden of Disease and Injury
Study 2004:
– Mental disorders contributed 8.6% of total
DALYs, ranking as the 4th leading cause of
disease burden
– Unipolar major depression accounted for
45% of total burden due to mental
disorders
Causes of DALYs, Malaysia 2000
(Malaysian Burden of Disease & Injury Study 2004)
Males: unipolar major depression was
9th leading cause (3% of 111 diseases)
 Females: unipolar major depression
was 3rd leading cause (5% of 111
diseases)

Leading causes of YLDs in
2004 (WHO 2008)

Unipolar depressive disorder ranked
first, for both males and females
– Males: 8.3% of total YLDs
– Females: 13.4% of total YLDs
NB: YLD = years lived with disability
Hidden morbidity

Patients often delay seeking
professional treatment for depression
(Olfson et al 1998)

Surveys in 6 Western European
countries found that only 36.6% of those
with active depression in the last 1 year
received any professional treatment
during the subsequent year
(ESEMeD/MHEDEA 2000 Investigators 2004)
Roles of healthcare
providers
Level
People
responsible
Level
1
Primary care
Assistant medical
officer
Nurses
Medical Officer
Level
2
Primary Care
Family Medicine
Specialist
Medical Officer
Level
3
Primary Care
Family Medicine
Specialist
Focus of Disease
Action
Recognition
Screening
Mild Depressive Episode
Psychological Intervention(counselling , problem solving
and supportive psychotherapy)
± Medication
Moderate Depressive Episode
Medication
Psychological Intervention
Referral to secondary care if
indicated including for
cognitive behaviour therapy
(CBT)
Level
People
responsible
Level
4
Secondary
Care
Outpatient
psychiatric
services
Level
5
Secondary
Care
In-patient
setting
Focus of Disease
Action
Moderate to Severe
Episode
Medication
Psychological intervention
including CBT
Risk to self/others
Severe self neglect
Psychotic symptoms
Lack of impulse control
Medication
Psychological intervention
including CBT
ECT
Assessment &
Diagnosis
Screening for depression
Two-question Case Finding Instrument
Evaluate for depression if “Yes” to either
question
Sensitivity 96%, specificity 57%
PPV 33%, NPV 98% (at prevalence of 18%) (Whooley et al
1997)
At estimated local prevalence of 5.6%
PPV = 12%
 NPV = 99.6%

ICD-10 criteria
Typical symptoms of depressive
episodes
Depressed mood
 Loss of interest & enjoyment
 Reduced energy

ICD-10 criteria
Common symptoms of depressive episodes
 Reduced
concentration & attention
 Reduced self-esteem & self –
confidence
 Ideas of guilt & unworthiness
 Bleak & pessimistic views of the future
 Ideas or acts of self-harm or suicide
 Disturbed sleep
 Diminished appetite
ICD-10 criteria contd..

Mild Depressive Episode
 At
least 2 typical symptoms + 2
common symptoms
 No symptom should be present to an
intense degree
 Minimum duration of whole episode is at
least 2 weeks
 The person has some difficulty in
continuing ordinary work & activities
ICD-10 criteria contd..

Moderate depressive episode
 At
least 2 typical symptoms + 3
common symptoms
 Some symptoms may be present to a
marked degree
 Minimum duration of whole episode is at
least 2 weeks
 The person has considerable difficulty in
continuing social, work or domestic
activities
ICD-10
contd..episode

Severecriteria
depressive
without
psychotic symptoms
 All
3 typical symptoms + at least 4
common symptoms
 Some of the symptoms are of severe
intensity
 Minimum duration of whole episode is at
least 2 weeks ( may be <2 weeks if
symptoms are very severe & of very
rapid onset.
 The person is very unlikely to continue
with social, work or domestic activities
ICD-10
criteria
contd..
 Severe depressive episode with
psychotic symptoms
A
severe depressive episode
 Delusions, hallucinations or depressive
stupor are present
Referral to Psychiatric Services










Unsure of diagnosis
Attempted suicide
Active suicidal ideas/plans
Failure to respond to treatment
Advice on further treatment
Clinical deterioration
Recurrent episode within 1 year
Psychotic symptoms
Severe agitation
Self neglect
Common criteria for psychiatric
admission include:
 Risk
of harm to self
 Psychotic symptoms
 Inability to care for self
 Lack of impulse control
 Danger to others
Psychological interventions
Counselling

A systematic process which gives individuals
an opportunity to explore, discover and clarify
ways of living more resourcefully, with a
greater sense of well-being. (British Association
for Counselling and Psychotherapy)

Concerned with addressing and resolving
specific problems, making decisions, coping
with crises, working through conflict or
improving relationships with others.
Problem solving therapy
•
•
Time-limited, structured intervention
that focuses on learning to cope with
specific problem areas.
Therapist and patient work
collaboratively.
Supportive therapy

Any form of treatment intended to
relieve symptoms or help the patient live
with them rather than attempt changes
character structure.
Components of supportive
therapy







Reassurance
Explanation
Guidance
Suggestion
Encouragement
Effecting changes in patient’s environment
Allowing catharsis
Cognitive Behaviour Therapy
Basic idea is that it is not events that
distress us, but what we think about
them
 CBT helps patients become aware of
their own thoughts and replace them
with more realistic thoughts

Computerised cognitivebehaviour therapy (CCBT)
•
The delivering of CBT via an interactive
computer interface. It may be used for mild to
moderate depression.
• Examples of programmes available over the
internet:
–
–
–
–
Moodgym
Beating the Blues (BtB)
COPE
Overcoming depression
Psychodynamic
psychotherapy
Patient explores feelings, and conscious
and unconscious conflicts originating in
the past, and gains insight.
 Should be reserved for selected
patients, e.g. those with complex comorbidities, personality problems,
traumatized persons and those with comorbid anxiety disorders.

Interpersonal therapy
A time-limited , structured psychological
intervention that focuses on
interpersonal issues.
 Therapist and patient work to identify
the effects of problems related to:

– interpersonal conflicts
– role transitions
– grief and loss
– social skills
PHARMACOTHERAPY
Phases of pharmacotherapy
Acute Phase
A period where remission is achieved.
 Continuation Phase
A period after sustained and complete
remission from the acute phase. Usually
a period of 6-9 months.
 Maintenance Phase
A period to prevent recurrence (a new
episode of depression) and to prevent
the development of chronicity.

Acute phase
pharmacotherapy
Mild depressive episode


May exercise the option of treating by
non-pharmacological means alone, viz.
problem-solving,
counselling,
and
supportive therapy, and exercise as an
adjunct.
Close follow-up appointment (within 2
weeks) so that patient’s condition can
be monitored closely.
Consider antidepressant
medication:
If depression persists or worsens
 If patient had a past history of moderate
to severe depression, and now presents
with a mild depressive episode
 When the patient is experiencing
ongoing stressors that may perpetuate
or worsen the depression

Moderate-severe depressive
episode

Offer antidepressants
 Drug of first choice is an SSRI
– Fluoxetine
– Fluvoxamine
– Sertraline
– Escitalopram
– Paroxetine
– Citalopram
Role of benzodiazepines
Failed response to initial
treatment

Patients who have not responded after
4 weeks of antidepressant therapy at an
adequate dose are acute phase nonresponders.
Apparent non-response
This may be due to:
– incorrect diagnosis
– psychotic depression
– organic conditions
– co-morbid psychiatric disorder
– adverse psychosocial factors
– non/poor compliance
Apparent non-response

If these other causes of apparent nonresponse have been ruled out, the
further strategies to follow are:
– Optimisation
– Switching
Optimisation

If there are no significant side effects,
increase the dose of medication
gradually until
– response is achieved
– or to the maximum dose that can be
tolerated
– or until the maximum allowable dose is
achieved
Switching
This refers to a change of
antidepressant.
 You may switch within the same class
of antidepressant (i.e. SSRI) or to
another class.
 Reduce the dose of the first
antidepressant gradually and slowly
titrate upwards the dose of the new
antidepressant.

Treatment-resistant
depression
Depression that has failed to respond to
two or more antidepressants given
sequentially at an adequate dose for an
adequate duration of time.
 Adequate dose is at least 150 mg/day
imipramine equivalent
 Adequate duration refers to at least 4
weeks.

Continuation phase
pharmacotherapy
After remission is achieved, continue
antidepressants for another 6-9 months
 Use the same dose as for the acute
phase

Maintenance phase
pharmacotherapy
Not all patients will need to go on to the
maintenance phase pharmacotherapy
 Maintenance phase treatment should be
considered for the following:

– 3 or more episodes of depression
– 2 episodes with severe functional
impairment
Maintenance phase
pharmacotherapy contd...
– 2 episodes of depression, plus one or more
of the following:
–family history of bipolar disorder
–history of recurrence within 1 year
after discontinuation of medication
–family history of recurrent major
depression
–early onset (< age 20) of first
depressive episode
Maintenance phase
pharmacotherapy contd...
–depressive episodes were severe,
sudden, or life threatening within the
past 3 years
– Residual symptoms
– Co-morbid dysthymic disorder, substance
abuse or anxiety disorders
(Bauer et al 2002, AHCPR 1993)
Discontinuation of medication
Drug therapy should not be terminated
abruptly
 The medication should be tapered down
gradually over weeks and sometimes
even months

Electroconvulsive therapy

Effective and rapid form of somatic treatment
for major depressive disorder
 Indications:
– High degree of symptom severity and functional
impairment
– Psychotic symptoms
– Catatonic features
– Urgent response needed/life-threatening condition
OTHER THERAPIES
Exercise Therapy
Structured and supervised exercise
activity 40-60 minutes per session, up to
3 times per week and prescribed for
10-12 weeks has been shown to be
effective.
 For practical purposes at least 30
minutes of daily moderate aerobic
exercise is recommended.

Social rhythm/ lifestyle
Rhythm and regularity of activities are
important for mental health
 Interaction with significant others
reduces isolation
 Schedule activities (rest and recreation)
that involve others
 Proper diet and exercise are helpful
 Maintain regular sleeping hours

Guideline implementation priorities

Training module
– Manual
– PowerPoint presentations
– Video vignettes
Quick reference for healthcare providers
 Patient information leaflet

Note: these slides are a distillation of the
information contained in the CPG, with
some additional material on burden of
disease.