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Depression & suicide

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  • 1. DEPRESSION & SUICIDE DR.SARATH MENON.R DEPARTMENT OF NEUROLOGY MGM MEDICAL COLLEGE,INDORE
  • 2. INTRODUCTION  Mood disorder  Syndrome- set of symptoms - definite time period  For atleast 2 weeks  Distress to self and others  Social & vocational impairment
  • 3. EPIDEMIOLOGY  Global prevalance 1.9 % (men) 3.3 % (women)  In India  Prevalence – 26.8 % (2011)  Suicidal mortality rate- 10.5/1L (2011) Studies  Chandrasekhar & Reddy etal (Hyderabad) prevalence -7.9 to 8.9 /1000 double prevalance rate in urban population
  • 4. STUDIES  South India- Chennai based study prevalence of 15.6 %  Srinath etal study ( Andhra) 1.61/1000 children – unipolar depression
  • 5. DETERMINANTS OF DEPRESSION  Female gender  Old age  Economic impoverishment  Illiteracy  Violence /trauma  Substance abuse –alcoholism  Chronic medical illness
  • 6. IMPACT ON MORTALITY  Around 8,00,000 commit suicide  India has highest suicidal rate among young people  70 % increase in mortality in people age > 65 yr
  • 7. THREE TYPES OF DEPRESSION  Major depression  Minor depression (dysthymia)  Bipolar depression
  • 8. MAJOR DEPRESSION- DSM IV CRITERIA  2 week duration  5 or more symptoms - depressed mood most of the days - diminished interest or pleasure - significant weight loss (>5% in a month) - insomnia/hypersomnia nearly every day - psychomotor agitation/ retardation - fatigue/ loss of energy - feeling of worthlessness/guilt - recurrent thoughts of death/suicidal ideation
  • 9. MINOR DEPRESSION  Often referred as dysthymia  Symptoms are same as major depression  Low level doesn’t disrupt one’s life  Duration of atleast 2 yrs  Chances to develop into major depression if untreated
  • 10. BIPOLAR DEPRESSION  Two sides of highs & lows  Symptoms of mania/hypomania in one side & major depression on other  Can fluctuate between these stages  Rapid or sudden fluctuations seen at times
  • 11. CLINICAL SUBTYPES OF DEPRESSION  Retarded depression  Agitated depression  Psychotic depression  Paranoid depression  Peuperial depression  Seasonal depression  Chronic depression
  • 12. ETIOLOGY  Biological factors - serotonin - norepinephrine - dopamine  Neuroendocrine regulation - thyroid axis - adrenal axis - growth hormone  Sleep abnormalities - delayed sleep onset - shortened REM latency
  • 13.  Brain imaging - Bipolar – enlarged cerebral ventricle - SPECT /PET scan- decreased blood flow esp. frontal cortex  Genetics - Psychisocial factors stress premorbid personality cognitive factors negative distortion of factors - negative self evaluation - pessimism - hopelessness
  • 14.  Positron Emission Tomography (PET) Scan often used to see shrinkage of the hippocampus and frontal lobe . (“Position Emission Tomography Scan of the Brain for Depression”)
  • 15. SEROTONIN  Imbalance in Serotonin can influence mood and emotions  Problems in the brain with low levels of Serotonin: the brain being unable to receive Serotonin and/or an overall shortage of Serotonin in the brain are being linked to Depression and it’s symptoms
  • 16. PATHOPHYSIOLOGY & CLINCAL PRESENTATION OF DEPRESSION  Mood disturbances - painful arousal - hypersensitivity to unpleasant event - insensitivity to unpleasant event - depressed mood - anhedonia - reduced anticipatory pleasure  Psychomotor disturbances - pyschomotor retardation - agitation - pseudi dementia/stupor
  • 17.  Cognitive disturbances - ideas of deprivation & loss - low self esteem & self confidence - self reproach & pathological guilt - recurrent thought of death & suicide  Vegetative disturbances -anorexia, weight loss or gain -insomnia/hypersomnia - sexual dysfunction  Suicide  Anxiety  Guilt
  • 18. SYMPTOMS OF DEPRESSION  Feeling sad, empty, nervous for a long time  Feeling hopeless, helpless, pessimistic  Problems sleeping, waking early in the morning and unable to get back to sleep  Loss of interest or enjoyment in hobbies, activities previously enjoyed  Feeling worthless, guilty, overwhelmed, inadequate  Feeling tired, lazy, no energy or zest  Problems concentrating, thinking clearly, remembering things  Ambivalence, can’t make decisions  No appetite with weight loss or overeating with weight gain  Agitation, irritability, physical restlessness  Loss of interest or enjoyment in sex  Persistent thoughts of death or suicide  Physical symptoms (such as headaches, stomach distress, chest pain, chronic pain) that won’t go away despite treatment
  • 19. TREATMENT  Psychosocial therapy  Pharmacotherapy
  • 20. PSYCHOSOCIAL THERAPY  Interpersonal therapy  Cognitive therapy  Behaviour therapy
  • 21. PHARMACOTHERAPY- GENERAL GUIDELINES  Usual recovery by 1 month  3-4 weeks for anti-depressants to act  Choice of antidepressents determined by side effect profile,physical status,lifestyle  Dosage raised to max.recommended level & maintained for 4 or 5 wks
  • 22. DURATION & PROPHYLAXIS  Atleast 6 months or length of previous episode  Prophylactic Rx - seriousness of previous episodes - suicidal ideation - impairment of psychosocial functions
  • 23. INITIAL MEDICATION SELECTION  Depending on - chronicity - family history - prior treatment response - concurrent psychiatric / general condition - patient preference
  • 24. ACUTE TREATMENT FAILURE  Cannot tolerate side effects  idiosyncratic adverse side effects  inadequate clinical response  wrong diagnosis  Lack of partial response ( 25% symptom reduction) in 4 – 6 wks - change treatment  Can have a 2nd trial for another 4-6 wks.
  • 25. SELECTION OF 2ND TREATMENT OPTIONS  Switching to alternate treatment (preferred)  augmentation of current treatment  combination therapy of SSRI & Bupropion – widely employed  ECT effective in non responsive cases & acute severe depression.
  • 26. ANTIDEPRESSANTS Name Usual daily dose(mg) Side effects NE reuptake inhibitor Desipramine 75-300 Drowsiness,insomnia,agita tion, arrythmia.weight gain, anti cholinergic Nortriptyline 40-200 - Do- 5-HT reuptake inhibitors (SSRI) Citalopram 20-60 Insomnia, agitation, sexual dysfunction,GI distress, sedation Escitalopram 10-20 -do- Fluoxetine 10-40 -do- Fluvoxamine 100-300 -do- Paroxetine 20-50 -do- Sertraline 50-150 -do-
  • 27. Name Usual daily dose(mg) Side effects NE& 5-HT reuptake inhibitors Amitriptyline 75-300 Drowsiness,OSH,arrythmi a,weight gain,anticholinergic Imipramine 75-300 -do- + agitation,insomnia Venlafaxine 150-375 Sleep changes,GI distress.discontinuation syndrome Duloxetine 30-60 GI distress.discontinuation syndrome Pre & post synaptic active agents Mirtazapine 15-30 Sedation,weight gain
  • 28. Name Usual daily dose (mg) Side effects Dopamine reuptake inhibitor Bupropion 200-400 Insomnia,agitation,GI distress Mixed action agents Amoxapine 100-600 Drowsiness,insomnia/agita tion,arrythmia,weight gain,OSH,anticholinergic Clomipramine 75-300 drowsiness.,weight gain
  • 29. Discuss Choice of drug with patient Include : Therapeutic effects Adverse effects Discontinuation effects Start antidepressant Titrate to recognised therapeutic dose. Assess efficacy over 4-6 weeks Increase Dose Assess over a further 2-4 weeks Continue for 4-6 months at full treatment dose Consider longer–term treatment in recurrent depression Give an antidepressant from a different class Titrate to therapeutic dose. Assess over 4-6 weeks Give an antidepressant from a different class Titrate to therapeutic dose. Assess over 4-6 weeks, increase dose as necessary Refer to Suggested treatments for refractory depression No Effect Poorly tolerated Poorly tolerated or no effect No Effect Effective No Effect Effective Effective Effective
  • 30. Treatment of refractory depression OTHER REPORTED TREATMENTS (may be worth trying, but limited published support) Treatment Add bupropion 300 mg /day Add clonazepam 0.5- 1.0 mg at night Add mirtazapine 15-30 mg ON Add modafinil 100-200 mg/day Add risperidone 0.5-1.0 mg /day Ketoconazole 400-800 mg /day Oestrogens (various regimes used) SSRI + TCA (e.g. citalopram 20 mg / day with amitriptyline 50 mg /day Try S-adenosyl – I – methionine 400 mg / day im SNRI = reboxetine Add omega – 3 fatty acid (EPA 1 g daily)
  • 31. DEPRESSION IN MEDICAL DISORDERS  Neurological - CVA - migraine - dementia - Parkinons d/s - epilepsy - multiple sclerosis - Huntingtons d/s - Wilsons d/s  Endocrine - adrenal- cushings,addisons - hypothroidism - hyper/hypo parathyroidism  Infections/inflammatory - HIV,IMN,SLE, temporal arteritis
  • 32.  Drugs -analgesics- indometahcin,ibuprofen,opiates - antibiotics- ampicillin,metronidazole,tetracyclines - steroids- corticosteroids,OCP,prednisolone - antihypertensives- b-blockers,clonidine,reserpine - anti cancer- bleomycin,vincristine  Miscellaneous - cancers - uremia - vitamin deficiency - porphyria
  • 33. SUICIDE –INCIDENCE & PREVALENCE  1.2 lakh/yr suicidal deaths  4 lakh/yr attempt suicide  Majority of suicide (37.8%) -< 30 yr age gp.  77 % suicide - < 44 yr age- huge burden
  • 34. STUDIES  Venkoba Rao etal- Madurai - incidence- 43/1,00,0000 - fatality- 1/12 attempts  Hegde et al (Karnataka) - incidence rate- 10.2/1,00,000 - Male preponderance- 67%  Shukla et al (Jhansi) - 29/1,00,000 - 34/1lakh (women) & 24 /1 lakh (men)
  • 35. OTHER STUDIES  Banerjee etal (kolkata) - incidence – 43/1,00,000 - women – 79.3 % - 75 % -< 25 yr age
  • 36. SUICIDE & PSYCHIATRIC DISORDERS  Psychological autopsy studies done in various countries over almost 50 years report the same outcomes:  90% of people who die by suicide are suffering from one or more psychiatric disorders:  Major Depressive Disorder  Bipolar Disorder, Depressive phase  Alcohol or Substance Abuse  Schizophrenia  Personality Disorders such as Borderline
  • 37. RISK FACTORS FOR SUICIDE  Psychiatric disorders  Past suicide attempts  Symptom risk factors  Sociodemographic risk factors  Environmental risk factors
  • 38. RISK FACTORS Psychiatric Disorders  Most common psychiatric risk factors resulting in suicide:  Depression*  Major Depression  Bipolar Depression  Alcohol abuse and dependence  Drug abuse and dependence  Schizophrenia *Especially when combined with alcohol and drug abuse
  • 39. RISK FACTORS  Other psychiatric risk factors with potential to result in suicide (account for significantly fewer suicides than Depression):  Post Traumatic Stress Disorder (PTSD)  Eating disorders  Borderline personality disorder  Antisocial personality disorder
  • 40. RISK FACTORS  Major physical illness, especially recent  Chronic physical pain  History of childhood trauma or abuse  Family history of death by suicide  Substance abuse
  • 41. RISK FACTORS Sociodemographic Risk Factors Over age 65 White Separated, widowed or divorced Living alone Being unemployed or retired Occupation: health-related occupations higher ( doctors, nurses, social workers)
  • 42. METHODS OF SUICIDE  Hanging ( 31.7 %)  Poisoning –pesticide, drug overdose etc (34.8%)  Firearms – (8 %)  Drowning  Wrist cutting  Hypothermia  Electrocution  Jumping from height  Vehicular impact-rail,traffic collision  Immolation
  • 43.  Observable signs of serious depression  Unrelenting low mood  Pessimism  Hopelessness  Desperation  Anxiety, psychic pain, inner tension  Withdrawal  Sleep problems  Increased alcohol and/or other drug use  Recent impulsiveness and taking unnecessary risks  Threatening suicide or expressing strong wish to die  Making a plan  Giving away prized possessions  Purchasing a firearm  Obtaining other means of killing oneself  Unexpected rage or anger WARNING SIGNS
  • 44. PROPOSED DSM-V SUICIDE ASSESSMENT DIMENSION Level of concern about potential suicidal behavior: (sum of items coded as present) 1. 0: Lowest concern 2. 1-2: Some concern 3. 3-4: Increased concern 4. 5-7: High concern Suicide risk factor groups: 1. Any history of a suicide attempt 2. Long-standing tendency to lose temper or become aggressive with little provocation 3. Living alone, chronic severe pain, or recent (within 3 months) significant loss 4. Recent psychiatric admission/discharge or first diagnosis of MDD, bipolar disorder or schizophrenia 5. Recent increase in alcohol abuse or worsening of depressive symptoms 6. Current (within last week) preoccupation with, or plans for, suicide 7. Current psychomotor agitation, marked anxiety or prominent feelings of hopelessness
  • 45. PREVENTING SUICIDE Prevention within our community  Education  Screening  Treatment  Means Restriction
  • 46. CONCLUSION  Depression - common disorder  By 2025, major cause of morbidity & mortality  India has highest number of suicides among young people  Treatable but under diagnosed  Newer drugs with less side effects available.
  • 47. REFERENCES  Kaplan & Saddock’s Synopsis of Psychiatry-10th edition  Text book of depressive disorders by Maj & Sartorius -2nd edition  Indian journal of psychiatry