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RECOGNITION & TREATMENT OF DEPRESSION
Prof. Fareed Aslam MinhasMB,MCPS,Dip.Psych,MSc,MRCPsych
HeadInstitute of Psychiatry
Rawalpindi Medical CollegeRawalpindi.
EVIDENCE FOR MENTAL DISORDERS CAUSING SUBSTANTIAL BURDEN GLOBALLY
• Estimated percent of DALY (Disability adjusted life years) for Neuropsychiatric disorders world-wide:
1990 – 10.5%1998 – 11.5%2020 – 15%
• 1990 estimate of DALY lost, range from 25% in Established Market Economies (EME) to 7% in developing countries.
• 1998 estimate range from 23.5% in high-income countries to 10.5% in low/medium income countries.
GLOBAL DISTRIBUTION OF HEALTH BURDENS, 1995:
Rank Cause %DALYs loss
• Lower respiratory diseases 7.3• Diarrhoeal diseases 6.5• Perinatal conditions 6.1• Unipolar Major Depression 4.2• Ischaemic Heart Disease 4.0• HIV 3.4• Cerebrovascular disease 3.2• Motor vehicle accidents 3.0• Malaria 3.0• Tuberculosis 3.0__________________________________________________________Major depression is estimated to become the second largest contributor to
DALYs by 2020
Disease Burden in Depression
• Functional disability is high 1
• Disability is greater when depression co-exists with other psychiatric conditions such as panic disorder or generalized anxiety disorder 2, 3
• The rate of attempted suicide is 15%; this figure rises when comorbid psychiatric disorders are present 4
Disease Profile
Depression…the most common psychiatric disorder that primary care clinicians
encounter.
• A prevalent and a serious psychiatric disorder
• Risk of suicide is high among individuals with depression
• Symptoms of depression are made more severe by the co-existence of anxiety
• People can experience depression at any time of life
THE BROAD IMPACT OF MENTAL ILLNESS
FearPersonal safetyTax burdenWider society
Staff moraleCriminal Justice
PsychiatryService system
Carer burdenLost employment
Travel cost, fees
Family
Quality costsLost employment
Service feesPatient
Intangible cost
Indirect costs
Direct cost
Examples of Impact Level
AFFECTIVE DISORDERSICD 10
• MANIC EPISODE
• BIPOLAR AFFECTIVE DISORDERS
• DEPRESSIVE EPISODE
• RECURRENT DEPRESSIVE DISORDERS
• PERSISTENT MOOD DISORDERS
• RECURRENT BRIEF DEPRESSION.
Types of Depression in Primary Care
• Anxious Depression
• Chronic Anxious Depression
• Depression with Somatic Symptoms
• Treatment Resistant Depression
• Bipolar Depression
Anxious depression
• Commonest kind of depressive disorder in general medical practice.
• Co-Morbid Depression and Generalized anxiety
• Often very severe disorder.
• Should be offered a sedating antidepressant.
• Depression without anxiety is less common in primary care
• May need an alerting antidepressant.
Chronic Anxious Depression
Some patients are usually well known to their doctors, have been symptomatic for many years.
Important not to treat with many different drugs and try to confine yourself only to those that are effective for that individual.
These patients often have • Intractable or insoluble life problems• It is unreasonable to suppose that these problems will
disappear with drug treatment.
• Arrange to see these patients at Regular Intervals
• If left to themselves, they often arrive more frequently.
• Spend time with them discussing their personal problems,
• Perform physical examinations for any physical disorders
• If new physical symptoms arise.
Depression with somatic symptoms
These can be divided into two groups
• Those whose physical symptoms are part of an undoubted physical illness.
• Those for whom no physical cause can be found, despite physical examination and any necessary investigations.
• Neither group consider themselves depressed. • They will readily admit to depressive symptoms if asked
directly• They improve considerably on anti-depressants.
• Doctors are typically distracted by the somatic symptoms, so that the psychiatric disorder goes undetected.
• • These group are best managed with Re-Attribution
Treatment-Resistant Depression
Refers to any patientDoes not respond to drug treatment given at the proper
dosage for an adequate time
About one third of depressed patients fall into this category.
Have to think of an antidepressant in another category; if this is not effective, a combination of drugs may be necessary.
Alternately refer to a psychiatrist.
Bipolar depression
• These are relatively rare is general practice.
• They have experienced episodes of mania or hypomania at some time in their past.
• They merit a psychiatric opinion,
• As antidepressants will sometimes precipitate an episode of hypomania.
USEFUL TERMS
• DEPRESSED MOOD
• DEPRESSIVE SYNDROME
• DEPRESSIVE ILLNESS
CORE SYMPTOMS OF MAJOR DEPRESSION
• Depressed mood.• Diminished interest or pleasure in activities.• Significant change in appetite and/or weight.• Insomnia or hypersomnia. • Psychomotor agitation or retardation.• Fatigue or loss of energy.• Lack of concentration or indecision. • Thoughts of death or suicide. • Anxiety, Pain and GI Symptoms.
SOMATIZATION
• Because it hurts.
• Indicates serious physical illness.
• Differential reinforcement by doctors.
• Differential reinforcement by relatives.
• Social stigma attached to emotional illness.
• Does not need to blame himself.
SOMATIC PRESENTATION IN MEDICAL SETTINGS.
• In primary care 1 in 5 new consultations are for somatic symptoms for which no specific cause is found. ( Goldberg & Bridges 1998)
• In hospital settings, medically unexplained somatic complaints are among the most common reasons for referral from primary care.
• Specific symptoms tend to cluster in medical specialties according to the organ system.
• The somatic symptoms of 1/3 of all patients seen in these clinics remain medically unexplained at the time of discharge. (Hamilton et al. 1996)
Depression with Anxiety
• 60 to 90% of depressed patients have anxiety symptoms
• Coexistent anxiety and depression results in
• more severe symptomology
• reduced treatment response
• worse prognosis
Profile of the Anxious Depressed Patient
• More impaired functioning compared with primary depression
• Increased agitation, hypochondriasis, depersonalization, chronic depression
• Reduced response to drug therapy and psychosocial intervention
• More severe and chronic illness
Stavrakaki C, The relationship of anxiety and depression: a review of the literature. British journal of Psychiatry 1986: 149: 7-16
PATHWAYS TO CAREGoldberg & Huxley
Level 1. Morbidity in Random Community Samples___________________________________________________________
Level 2. Total Psychiatric Morbidity in Primary Care.___________________________________________________________
Level 3. Conspicuous Psychiatric Morbidity___________________________________________________________
Level 4. Total Psychiatric Patients___________________________________________________________
Level 5. Psychiatric in-Patients
STRESS & PSYCHIATRIC DISORDERS IN RURAL PUNJAB.
British Journal Of Psychiatry(1997),170,473-478
• 66% of women, 25% of men suffered from Depressive and Anxiety disorders.
• Levels of emotional distress increased with age in both genders.
• Women living in unitary households reported more distress than those living in extended or joint families.
• With younger men and women, lower levels of education were associated with greater risk of Psychiatric disorders.
• Social disadvantage was associated with more emotional distress.
STRESS & PSYCHIATRIC DISORDERS IN URBAN RAWALPINDI
British Journal of Psychiatry (2000)-177,557-562
• 25% of women, 10 % of men suffered from Depressive and anxiety disorders.
• Levels of emotional distress increased with age.
• Women living in joint households reported more distress than those living in unitary families.
• Higher levels of education were associated with lower risk of common mental disorders.
• Emotional distress was negatively correlated with socio economic variables among women.
PRIMARY CARE SETTING.Gujar Khan
• 20-40% suffered from Depression and anxiety.
• More in females.
• Primary care physicians diagnosed depression in 58% of cases.
• 87% of patients presented with aches and pains .
THE PREVALENCE, CLASSIFICATION AND TREATMENT OF MENTAL DISORDERS AMONG ATTENDERS OF
NATIVE HEALERS IN RURAL PAKISTAN.Soc Psychiatry Psychiat Epidemiol(2000) 35: 480-485
• 61% of the attenders had psychiatric disorders.
• 29% female and 15 % males suffered from major depressive episode.
• 15% suffered from generalized anxiety disorder
• 8% suffered from dissociative disorders.
• 9% suffered from epilepsy.
PERCENTAGE OF MAJOR DIAGNOSTIC CATEGORIES DURING FOUR YEARS IN IOP
Journal of CPSP (2001)
Fig.3 Percentage of major diagnostic categories.
0.00%5.00%
10.00%15.00%20.00%25.00%30.00%35.00%40.00%
overall%
Males
Females
overall% 8.40% 37% 11.40% 4.80% 10.60% 1.50% 1.43% 4.80%
Males 5.70% 18% 4.15% 2.90% 10.60% 0.92% 0.95% 0.60%
Females 2.70% 19% 7.20% 1.90% 0% 0.66% 1.90% 4.20%
Scizophr
enia
Depressi
onBipolar Mania
Drug
Depende
Personal
ityOCD
Conversi
on
Postnatal depression in developing countries
Goa, IndiaPrevalence 23%
Patel et al., 2002. American Journal of Psychiatry; 159: 43-47
Dubai, United Arab EmiritesPrevalence 15.8%
Ghubash & Abou-Saleh, 1997. British Journal of Psychiatry; 171: 65-68
Khayelitsha, South AfricaPrevalence 34.7%
Cooper et al., 1999. British Journal of Psychiatry; 175: 554-58
Antenatal and Postnatal depression in a rural community
Rawalpindi, PakistanRahman, et al 2003. Psychol Med 33:1161-67
• Rural, community-based sample of 670 women• Single phase, SCAN • Prevalence 25% in antenatal period; 28% in postnatal
period• Depressed mothers significantly more disabled• Risk factors include husband’s unemployment,
relationship difficulties, 2 or more young children• Protective factors include family support in child care,
presence of infant’s grandmother, able to complete ‘chilla’ period, financial autonomy
Can maternal depression increase infant risk of illness and growth impairment in
developing countries?Rahman et al. 2002. Child: Care, Health &
Development 28: 51-56
Conclusion
Maternal depression is a major determinant of
infant growth and well-being
MEAN DURATION OF STAY IN DAYS FOR MAJOR DIAGNOSTIC CATEGORIES.
15.93
18.3
19.3
18.94
7.6 Depression
Schizophrenia
Hypomania
Bipolar
Drug Dependence
Measuring Improvement
• Improvement can be measured in terms of – symptoms,
– comorbid disorders,
– functional disability,
– and overall quality of life.
• Several clinician-rated scales exist for depression to measure severity of symptoms, and response to therapeutic intervention. – Hamilton rating scale for depression (HAM-D) - symptoms
Looking Up:Improving the
Management of Depression
0
20
40
60
80
100
ReceivingAntidepressant
Receiving AdequateDose
Wells KB et al. Am J Psychiatry. 1994;151:694-700.
% ofDepressed Patients
Depression Is Underdiagnosed and Undertreated
22.713.7
Medical Outcomes Study
90%80%
50%
0%
50%
100%
After 1 Episode After 2
Episodes
After 3
Episodes
Kupfer DJ. J Clin Psychiatry. 1991;52:(suppl 5):28-34.
Probability ofRecurrent Episodes
Depression Is a Chronic Illness
Defining outcomes and phases
of treatment
Adapted from Kupfer. J Clin Psychiatry 1991; 52 (Suppl 5): 28-34.
Euthymia
Symptoms
Syndrome
Treatment phases
Pro
gre
ssion
to d
isord
er
Acute(6-12 weeks)
Continuation(4-9 months)
Maintenance(>1 year)
Relapse
Response
RecurrenceRelapse
Remission
TIME
STEPS: Factors to Consider in Antidepressant Selection
• Safety– Drug-drug interaction potential
• Tolerability– Acute and long term
• Efficacy– Onset of action– Treatment and prophylaxis– Activity in subpopulations
• Payment (cost-effectiveness)
• Simplicity– Dosing– Need for monitoring
ANTIDEPRESSANTS GROUPS AND NAMES
• TCAs Tricyclic Antidepressants. • SSRI Selective Serotonin Reuptake Inhibitor• RIMA Reversible Inhibitor of Mono Amino Oxidase• SNRI Serotonin and Noradrenalin Reuptake Inhibitor• NaSSA Noradrenergic and Specific Serotonergic
Antidepressant• DSA Daul Serotonergic Antidepressant• NARI NorAdrenalin Reuptake Inhibitor• (SNRI) Selective Noradrenalin Reuptake Inhibitor
ANTIDEPRESSANTS GROUPS AND PHARMACOLOGY (1)
• TCAs Amitriptyline, Doxepine, Trimipramine, Clomipramine and other.
• SSRI Fluvoxamine, Fluoxetine, Paroxetine, Sertraline, Citalopram
• RIMA Moclobemide – Reversible inhibitor, selective inhibition of MAO type A
• SNRI Venlafaxine– Reuptake inhibition NA/5-HT, no affinity to other systems
(?)
ANTIDEPRESSANTS GROUPS AND PHARMACOLOGY (2)
• NaSSA Mirtazapine 2 antagonist, 5-HT2 and 5-HT3 antagonist. H1 antagonist.
• DSA Nefazodone– 5-HT2 antagonist and 5-HT reuptake inhibitor
• NARI (SNRI) Reboxetine– Selective NA reuptake inhibitor
Side Effects of Concern With Antidepressant Therapy
CNS• Activation
– Insomnia– Anxiety– Nervousness– Agitation– Tremor– Seizures
• Sedation– Somnolence– Fatigue
GI• Nausea• Constipation• Diarrhea• Dyspepsia• Weight gain• Anorexia
Sexual function• Decreased libido• Impotence• Ejaculation disorder• Anorgasmia
Cardiovascular• Hypertension• Orthostatic hypotension• Arrhythmias
Other• Dry mouth• Increased sweating• Asthenia
OTHER THERAPIES FOR DEPRESSION
• Psychotherapy
• Electroconvulsive therapy
WHEN TO INVOLVE A SPECIALIST
• Persistent suicidal ideation or plan of action
• Development of psychotic or manic symptoms
• Poor or partial response to antidepressant
• Refusal of pharmacotherapy
• Complicating illness or concurrent medication
PATIENT FOLLOW-UP
• Regular monitoring of mental state
• Inform patients that improvement may not be apparent for 2 weeks on antidepressants
• Clear instructions regarding medication and importance of compliance
ANSWERS TO FREQUENTLY ASKED QUESTIONS
• Sleep disturbances may resolve relatively quickly with some agents
• Somatic complaints may resolve in a few weeks
• Other symptoms may take several weeks to resolve
• Compliance is essential
PSYCHOTHERAPY MAY BE INDICATED
• As an adjunct to drug therapy but is not a substitute for it
• In patients with milder depression who do not need or do not want drugs
LIFE-STYLE CHANGES
• Suggestions for life-style changes are not useful while patients are significantly depressed
• Patients should avoid alcohol and substances with potential for abuse while being treated
FOLLOW-UP THERAPY
• Continue antidepressants for several months or longer
• See patients frequently to assess mood and side effects
• When discontinuation is indicated, antidepressant dosages should be tapered
SUMMARY
• Affective disorders are as common in Pakistan as elsewhere in the world.
• Present with predominant Somatic symptoms.
• Not picked up by health professionals.
• Unnecessary investigations.
SUMMARY 2
• Even if recognized, treated with only Anti depressants.
• Teaching of Psychiatry at under & postgraduate levels.
• Integration into Primary Health Care System.
• Integration has positive effect on the utilisation of general health services.