they appear to relate: hence abdominal & bowel symptoms in GI clinics, ( Holmes et al 1987) headaches in neurology ,( Fitzpatrick&Hopkins 1987) chest pains & palpitations in cardiac clinic.(Mayou et al 1995)
The long-term treatment of mood and anxiety disorders has been defined in three phases relating to the possible outcomes in the course of the disorders. Acute treatment can enable an improvement in symptoms (response), which may lead to remission. Continuation treatment may enable treatment to sustain remission and achieve recovery and reduce the possibility of relapse. Maintenance treatment can be viewed as long-term therapy to sustain a period of recovery and prevent recurrence. Kupfer DJ. Long-term treatment of depression. J Clin Psychiatry 1991; 52 (Suppl 5): 28-34.
Depressive disorders prof. fareed minhas
RECOGNITION & TREATMENT OF
Prof. Fareed Aslam Minhas
Institute of Psychiatry
Rawalpindi Medical College
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
Lower respiratory diseases
Unipolar Major Depression
Ischaemic Heart Disease
Motor vehicle accidents
Major depression is estimated to become the second largest contributor to
DALYs by 2020
Disease Burden in
• 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
Depression…the most common psychiatric
disorder that primary care clinicians
• 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 coexistence of anxiety
• People can experience depression at any time of life
THE BROAD IMPACT OF MENTAL
Examples of Impact
Indirect costs Intangible cost
Types of Depression in
• Anxious Depression
• Chronic Anxious Depression
• Depression with Somatic Symptoms
• Treatment Resistant Depression
• Bipolar Depression
• Commonest kind of depressive disorder in general medical
• 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
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
These can be divided into two groups
• Those whose physical symptoms are part of an undoubted
• 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
• 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
Refers to any patient
Does 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
• 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
CORE SYMPTOMS OF MAJOR
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.
• 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
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
Depression with Anxiety
• 60 to 90% of depressed patients
have anxiety symptoms
• Coexistent anxiety and depression
• more severe symptomology
• reduced treatment response
• worse prognosis
Profile of the Anxious Depressed
• More impaired functioning compared with
• Increased agitation, hypochondriasis,
depersonalization, chronic depression
• Reduced response to drug therapy and
• 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 CARE
Goldberg & Huxley
Morbidity in Random Community Samples
Total Psychiatric Morbidity in Primary Care.
Conspicuous Psychiatric Morbidity
Total Psychiatric 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
• Levels of emotional distress increased with age in both
• 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
STRESS & PSYCHIATRIC DISORDERS IN URBAN
British Journal of Psychiatry (2000)-177,557-562
• 25% of women, 10 % of men suffered from Depressive and
• 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.
• 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
• 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.
MEAN DURATION OF STAY IN DAYS FOR
MAJOR DIAGNOSTIC CATEGORIES.
• Improvement can be measured in terms of
– 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
Depression Is Underdiagnosed and Undertreated
Medical Outcomes Study
Wells KB et al. Am J Psychiatry. 1994;151:694-700.
Depression Is a Chronic Illness
After 1 Episode
Kupfer DJ. J Clin Psychiatry. 1991;52:(suppl 5):28-34.
Defining outcomes and phases
Adapted from Kupfer. J Clin Psychiatry 1991; 52 (Suppl 5): 28-34.
STEPS: Factors to Consider in Antidepressant
– Drug-drug interaction potential
– Acute and long term
– Onset of action
– Treatment and prophylaxis
– Activity in subpopulations
• Payment (cost-effectiveness)
– 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
• DSA × Daul Serotonergic Antidepressant
• NARI × NorAdrenalin Reuptake Inhibitor
• (SNRI) × Selective Noradrenalin Reuptake Inhibitor
ANTIDEPRESSANTS GROUPS AND
• TCAs × Amitriptyline, Doxepine, Trimipramine, Clomipramine
• SSRI × Fluvoxamine, Fluoxetine, Paroxetine, Sertraline,
• 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
• 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
• Weight gain
• Decreased libido
• Ejaculation disorder
• Orthostatic hypotension
• Dry mouth
• Increased sweating
OTHER THERAPIES FOR
• Electroconvulsive therapy
WHEN TO INVOLVE A
• 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
• 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
• Sleep disturbances may resolve relatively quickly
with some agents
• Somatic complaints may resolve in a few weeks
• Other symptoms may take several weeks to
• Compliance is essential
PSYCHOTHERAPY MAY BE
• 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
• 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
• Continue antidepressants for several months or
• See patients frequently to assess mood and side
• When discontinuation is indicated, antidepressant
dosages should be tapered
• 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.
• Even if recognized, treated with only Anti
• Teaching of Psychiatry at under & postgraduate
• Integration into Primary Health Care System.
• Integration has positive effect on the utilisation
of general health services.
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