* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download 私人精神科醫生分享處理長者抑鬱的經驗Sad, Bad or Mad
Separation anxiety disorder wikipedia , lookup
Psychedelic therapy wikipedia , lookup
David J. Impastato wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
Child psychopathology wikipedia , lookup
History of psychiatry wikipedia , lookup
Mental status examination wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
Bipolar II disorder wikipedia , lookup
History of mental disorders wikipedia , lookup
Emergency psychiatry wikipedia , lookup
Abnormal psychology wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
Moral treatment wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
Postpartum depression wikipedia , lookup
Behavioral theories of depression wikipedia , lookup
Major depressive disorder wikipedia , lookup
Evolutionary approaches to depression wikipedia , lookup
Biology of depression wikipedia , lookup
‘Sad, Bad or Mad’ a private psychiatrist’s experience on Elderly Depression 從一位私人精神科醫生的角度看 長者抑鬱症 Dr. Ip Yan Ming 叶恩明医生 Vice-President Hong Kong College of Psychiatrists Sad, Bad or Mad ? 不開心? 不好? ? • People lives longer nowadays • Older & wiser • But more likely to have losses (of health, loved ones & social horizon) • When depressive disorder appears, it may neither be sad, bad nor mad. Sad, Bad or Mad ? 不開心? 不好? ? But many people assume: • Depression equals to sadness and is a normal part of ageing that will go away by itself. • If nothing bad has happened to him/her, one should not be sad. • It’s bad to bother others with sadness. • Seeing psychiatrist is a sign of madness. Depression in the Elderly 長者抑鬱症 Under-diagnosed & under-treated Not uncommon Treatable > 50% diagnosed or treated inappropriately Worsen quality of life Increase morbidity & mortality 15% suicide 餘暉心態 老,不一定沉鬱消極 Prevalence (發病率) of elderly depression in different care settings Care setting Prevalence of depressive symptoms Community 15% Prevalence of major depressive disorder 1-3% Primary care 20% 10-12% Acute hospital 20-25% 10-15% Residential care 30-40% 16% Diagnosis ( 断症 ) A syndromal diagnosis (clinical) Based on eliciting specific symptom cluster through careful history taking and mental state examination ICD-10 or DSM-IV ICD-10 Cardinal symptoms: 1. abnormal depressed mood for >2 weeks, 2. loss of interest / pleasure (anhedonia), 3. loss of energy (anergia) Additional symptoms: 1. loss of confidence / self esteem, 2. inappropriate guilt, 3. suicidal thoughts / behaviour, 4. diminished ability to think / concentrate, 5. psychomotor changes, 6. sleep disturbance, 7. appetite changes DSM-IV 1. 2. 3. 4. 5. 6. 7. 8. 9. -- Depressed mood most of the day Marked diminished interest or pleasure Significant weight or appetite change Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive guilt Reduced ability to think or concentrate Recurrent suicidal thoughts or attempts 5 or more s/s for >2 weeks , must have (1) or (2) Diagnostic difficulties (難處) Presentation of depression in the elderly may be modified by factors associated with old age Primary care physicians could identify no more than 50% of patients with a diagnosable depressive syndrome (Mulsant & Ganguli, 1999) Peculiar features of elderly depression (特点) Minimisation of sadness (Georgotas, 1983) Somatisation or disproportionate complaints associated with physical disorder (Sheehan et al, 2003) "Neurotic" symptoms of recent onset "Trivial" acts of deliberate self-harm "Pseudodementia" Recent change in behaviour (‘out of character’) Assessment (評估) History (both from patient & informant) Mental state examination Use of standardised instruments, e.g. Geriatric depression scale (GDS) Cognitive assessment Physical examination Investigation Geriatric Depression Scale (GDS) 老人憂鬱量表 Validated standardized scales for screening of depression: 15-item Chinese Geriatric Depression Scale Short Form (GDS) (Lee et al, 1993) Cut-off point of 8/15 Can be applied by trained non-medical personnel 老人憂鬱量表 以下列舉的問題是人們對一些事物的感受。在過去一星期內,你是否曾有以下 的感受,如有的話,請圈「是」,若無的話,請圈「否」。 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 你基本上對自己的生活感到滿意嗎? 你是否已放棄了很多以往的活動和嗜好? 你是否覺得生活空虛? 你是否常常感到煩悶? 你是否很多時感到心情愉快呢? 你是否害怕將會有不好的事情發生在你身上呢? 你是否大部份時間感到快樂呢? 你是否常常感到無助?(即是沒有人能幫自己) 你是否寧願留在家裏,而不愛出外做些有新意的事情?(譬 如 : 和家人到一新開張酒樓吃飯) 你是否覺得你比大多數人有多些記憶的問題呢? 你認為現在活著是一件好事嗎? 你是否覺得自己現在是一無是處呢? 你是否感到精力充足? 你是否覺得自己的處境無望? 你覺得大部份人的境況比自己好嗎? 第2, 3, 4, 6, 8, 9, 10, 12, 14, 15 題,答案「是」得1 分 第1, 5, 7, 11, 13 題,答案「否」得1 分 8 分 ===> 憂鬱的徵狀 是/否 是/否 是/否 是/否 是/否 是/否 是/否 是/否 是/否 是/否 是/否 是/否 是/否 是/否 是/否 Principles of management (處理的原则) Watch out for catastrophic risks Educating patient (& caregivers) about depression and involving them in Rx decisions 3. Treating the whole person - coexisting physical disorder; attention to sensory deficits and other handicaps; reviewing medication; psychosocial intervention 4. Treating depressive symptoms with aim of complete remission, then continue & maintain 5. Prompt referral of patients requiring specialist mental health services 1. 2. Treatment (治療) Physical treatment – Pharmacological treatment – Electroconvulsive therapy Psychosocial treatment The Monoamine Hypothesis The 3 monoamines: serotonin, noradrenaline and dopamine Depression believed to be a result of dysfunction of monoamine neurotransmitters All effective antidepressants act by increasing the synaptic concentration of these neurotransmitters in the brain by various mechanisms Biogenic Amine Imbalance Norepinephrine Energy Interest Anxiety Irritability Serotonin Mood, Impulse Emotion, Cognitive Sex function Appetite Motivation Aggression Drive Dopamine Pharmacological treatment (藥物治療) Information for patients and carers: – Start low, go slow – Typical side effects – Delay in onset of therapeutic action – Need for continuation treatment following initial response Tricyclic antidepressants (TCA) Nortriptyline, dothiepin, imipramine, amitriptyline, clomipramine, trimipramine - Anticholinergic S/E (urinary retention & constipation may be troublesome) - Anti-histaminergic S/E - Anti-adrenergic S/E - Cardiotoxicity - dangerous if overdose Mechanism of action of TCAs Shown here is an icon of a tricyclic antidepressant (TCA). These drugs are actually five drugs in one: (1) a serotonin reuptake inhibitor (SRI); (2) a noradrenaline reuptake inhibitor (NRI); (3) an anticholinergic/antimuscarinic drug (M1); (4) an alpha adrenergic antagonist (alpha); and (5) an antihistamine (H1). Stephen M. Stahl: Essential Psychopharmacology 1996 Selective Serotonin Reuptake Inhibitors (SSRIs) Citalopram (Cipram), sertraline (Zoloft), paroxetine (Seroxat), fluoxetine (Prozac), escitalopram (Lexapro), fluvoxamine (Faverin) - GI upset - Headache - Insomnia, anxiety, tremor - Sexual dysfunction (better tolerated than TCA but increase the risk of GI bleeding in the very old) Serotonergic-Noradrenergic Reuptake Inhibitor (SNRI) Venlafaxine (Efexor/Efexor XR) Duloxetine (Cymbalta) Milnacipran (Ixel) - Side effects similar to SSRI - Dizziness, increase heart rate - May cause hypertension at high doses Serotonin-2 Antagonist / Reuptake Inhibitors (SARI) trazodone (Trittico) - Very sedating - Dizziness, nausea, postural hypotension, rarely priapism, no anticholinergic S/E nefazodone (Serzone) - Less sedating, Other Antidepressants NaSSA – mirtazapine (Remeron) – Sedation, increased appetite, weight gain, oedema, (nausea & sexual S/E uncommon) NDRI – bupropion (Wellbutrin) – Headache, agitation, nausea, insomnia, (no sexual S/E) Mianserin (Tolvon): – Sedation, rash, rarely: blood dyscrasia, no anticholinergic S/E, sexual S/E uncommon Reversible inhibitors of monoamine oxidase A (RIMA) Moclobemide (Aurorix) - Nausea - Headache - Insomnia - Restlessness - Agitation Other pharmacological treatment Antipsychotics Lithium augmentation Tri-iodothyronine (T3) augmentation Antidepressant combination Anticonvulsant augmentation Buspirone augmentation Electroconvulsive therapy (ECT) Safe and effective Indicated if prompt effect is needed (in food refusal, suicidal risk, severe retardation) or refractory to drug treatment 71-88% with good outcome Post ECT confusion 18-52% Memory impairment is temporary Twice or three times weekly for 6 to 12 sessions Psychosocial interventions Basic psychotherapeutic processes: – *Establish Rapport – Listening and talking – Release of emotion – Giving information – Restoration of morale – Suggestion – Guidance and advice – The therapeutic relationship Psychoeducation Nature and pathogenesis of depression Use of a “Stress-diathesis” model Proposed treatment, expected side effects, delay in onset of therapeutic response Expected duration of continuation and maintenance treatment Evidence-based psychosocial treatments Interpersonal therapy Cognitive behavioural therapy For moderate to severe depression, the combination of pharmacotherapy and psychological treatment has been found to be superior to either treatment given alone (Reynolds et al, 1999) When to refer for specialist advice? (WPA, 1999) When diagnosis is in doubt (e.g. dementia?) When depression is severe, as evidenced by: – Psychotic depression – Severe risk to health because of failure to eat or drink – Suicide risk Complex therapy is indicated (e.g. in cases with medical comorbidity) When first-line therapy fails (although primary care physicians may wish to pursue a second course of antidepressant from a different class) & beyond the GP’s therapeutic limitation Referral to Psychiatric Service GP usually refer when: 1. their treatment has failed – commonest reason 2. pressure from patient or relatives 3. suicidal risks 4. social or behavioural (e.g. violent) crisis Tendency for non-referral or late referral Sad, Bad or Mad ? 不開心? 不好? ? In Summary: • Elderly Depression are not rare but often not detected or treated properly • It need not be sad, bad or mad. • Highly treatable & quality of life improves. • Treat with care, start low & go slow. • When in doubt, ready to refer or consult. The End