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RECOGNITION & TREATMENT OF
DEPRESSION
Prof. Fareed Aslam Minhas
MB,MCPS,Dip.Psych,MSc,MRCPsych

Head
Institute of Psychiat...
EVIDENCE FOR MENTAL DISORDERS CAUSING
SUBSTANTIAL BURDEN GLOBALLY
• Estimated percent of DALY (Disability adjusted life ye...
GLOBAL DISTRIBUTION OF HEALTH
BURDENS, 1995:
Rank

Cause

%DALYs loss

Lower respiratory diseases
7.3
•
•
Diarrhoeal disea...
Disease Burden in
Depression
• Functional disability is high 1
• Disability is greater when depression co-exists
with othe...
Disease Profile
Depression…the most common psychiatric
disorder that primary care clinicians
encounter.
• A prevalent and ...
THE BROAD IMPACT OF MENTAL
ILLNESS
Level

Examples of Impact
Direct cost

Indirect costs Intangible cost

Patient

Service...
AFFECTIVE DISORDERS
ICD 10

• MANIC EPISODE
• BIPOLAR AFFECTIVE DISORDERS
• DEPRESSIVE EPISODE
• RECURRENT DEPRESSIVE DISO...
Types of Depression in
Primary Care
• Anxious Depression
• Chronic Anxious Depression
• Depression with Somatic Symptoms
•...
Anxious depression
• Commonest kind of depressive disorder in general medical
practice.
• Co-Morbid Depression and General...
Chronic Anxious Depression
Some patients are usually well known to their doctors, have
been symptomatic for many years.
Im...
• Arrange to see these patients at Regular Intervals
• If left to themselves, they often arrive more frequently.
• Spend t...
Depression with somatic
symptoms
These can be divided into two groups
• Those whose physical symptoms are part of an undou...
Treatment-Resistant Depression
Refers to any patient
Does not respond to drug treatment given at the proper dosage
for an ...
Bipolar depression
• These are relatively rare is general practice.
• They have experienced episodes of mania or hypomania...
USEFUL TERMS
• DEPRESSED MOOD
• DEPRESSIVE SYNDROME
• DEPRESSIVE ILLNESS
CORE SYMPTOMS OF MAJOR
DEPRESSION
•
•
•
•
•
•
•
•
•

Depressed mood.
Diminished interest or pleasure in activities.
Signif...
SOMATIZATION
• Because it hurts.
• Indicates serious physical illness.
• Differential reinforcement by doctors.
• Differen...
SOMATIC PRESENTATION IN MEDICAL
SETTINGS.
•

In primary care 1 in 5 new consultations are for somatic symptoms
for which n...
Depression with Anxiety
• 60 to 90% of depressed patients
have anxiety symptoms
• Coexistent anxiety and depression
result...
Profile of the Anxious Depressed
Patient
• More impaired functioning compared with
primary depression
• Increased agitatio...
PATHWAYS TO CARE
Goldberg & Huxley

Level
1.
Morbidity in Random Community Samples
_______________________________________...
STRESS & PSYCHIATRIC DISORDERS IN RURAL PUNJAB.
British Journal Of Psychiatry(1997),170,473-478

• 66% of women, 25% of me...
STRESS & PSYCHIATRIC DISORDERS IN URBAN
RAWALPINDI
British Journal of Psychiatry (2000)-177,557-562

• 25% of women, 10 % ...
PRIMARY CARE SETTING.
Gujar Khan

• 20-40% suffered from Depression and anxiety.
• More in females.
• Primary care physici...
THE PREVALENCE, CLASSIFICATION AND TREATMENT
OF MENTAL DISORDERS AMONG ATTENDERS OF
NATIVE HEALERS IN RURAL PAKISTAN.
Soc ...
PERCENTAGE OF MAJOR DIAGNOSTIC
CATEGORIES DURING FOUR YEARS IN IOP
Journal of CPSP (2001)

Fig.3 Percentage of major diagn...
Postnatal depression in developing
countries
Goa, India
Prevalence 23%

Patel et al., 2002. American Journal of Psychiatry...
Antenatal and Postnatal depression in a
rural community
Rawalpindi, Pakistan
Rahman, et al 2003. Psychol Med 33:1161-67
• ...
Can maternal depression
increase infant risk of illness
and growth impairment in
developing countries?
Rahman et al. 2002....
Conclusion
Maternal depression is a major
determinant of
infant growth and well-being
MEAN DURATION OF STAY IN DAYS FOR
MAJOR DIAGNOSTIC CATEGORIES.

7.6

15.93

Depression
Schizophrenia

18.94

Hypomania
18....
Measuring Improvement
• Improvement can be measured in terms of
– symptoms,
– comorbid disorders,
– functional disability,...
Looking Up:
Improving the
Management of
Depression
Depression Is Underdiagnosed and Undertreated
Medical Outcomes Study
100
80
60
% of
Depressed Patients
40
22.7
13.7

20
0
...
Depression Is a Chronic Illness

100%
50%

80%

90%

50%

Probability of
Recurrent Episodes

0%
After 1 Episode

After 3

...
Defining outcomes and phases
of treatment
Remission
Relapse

Euthymia

Syndrome

Continuation
(4-9 months)

Maintenance
(>...
STEPS: Factors to Consider in Antidepressant
Selection
• Safety
– Drug-drug interaction potential
• Tolerability
– Acute a...
ANTIDEPRESSANTS GROUPS AND NAMES
TCAs × Tricyclic Antidepressants.
SSRI × Selective Serotonin Reuptake Inhibitor
RIMA × Re...
ANTIDEPRESSANTS GROUPS AND
PHARMACOLOGY (1)
• TCAs × Amitriptyline, Doxepine, Trimipramine, Clomipramine
and other.
• SSRI...
ANTIDEPRESSANTS GROUPS AND
PHARMACOLOGY (2)
• NaSSA × Mirtazapine
↑2 antagonist, 5-HT2 and 5-HT3 antagonist. H1 antagonist...
Side Effects of Concern With
Antidepressant Therapy
CNS
• Activation
– Insomnia
– Anxiety
– Nervousness
– Agitation
– Trem...
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...
PATIENT FOLLOW-UP
• Regular monitoring of mental state
• Inform patients that improvement may not be
apparent for 2 weeks ...
ANSWERS TO FREQUENTLY
ASKED QUESTIONS
• Sleep disturbances may resolve relatively quickly
with some agents
• Somatic compl...
PSYCHOTHERAPY MAY BE
INDICATED
• As an adjunct to drug therapy but is not a
substitute for it
• In patients with milder de...
LIFE-STYLE CHANGES
• Suggestions for life-style changes are not useful
while patients are significantly depressed

• Patie...
FOLLOW-UP THERAPY
• Continue antidepressants for several months or
longer
• See patients frequently to assess mood and sid...
SUMMARY
• Affective disorders are as common in Pakistan as
elsewhere in the world.
• Present with predominant Somatic symp...
SUMMARY 2
• Even if recognized, treated with only Anti
depressants.
• Teaching of Psychiatry at under & postgraduate
level...
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Depressive disorders-prof. fareed minhas

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  • 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)
  • <number>
  • 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.
  • Transcript of "Depressive disorders-prof. fareed minhas"

    1. 1. RECOGNITION & TREATMENT OF DEPRESSION Prof. Fareed Aslam Minhas MB,MCPS,Dip.Psych,MSc,MRCPsych Head Institute of Psychiatry Rawalpindi Medical College Rawalpindi.
    2. 2. 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.
    3. 3. 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
    4. 4. 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
    5. 5. 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 coexistence of anxiety • People can experience depression at any time of life
    6. 6. THE BROAD IMPACT OF MENTAL ILLNESS Level Examples of Impact Direct cost Indirect costs Intangible cost Patient Service fees Lost employment Quality costs Family Travel cost, fees Lost employment Carer burden Service system Psychiatry Criminal Justice Staff morale Wider society Tax burden Personal safety Fear
    7. 7. AFFECTIVE DISORDERS ICD 10 • MANIC EPISODE • BIPOLAR AFFECTIVE DISORDERS • DEPRESSIVE EPISODE • RECURRENT DEPRESSIVE DISORDERS • PERSISTENT MOOD DISORDERS • RECURRENT BRIEF DEPRESSION.
    8. 8. Types of Depression in Primary Care • Anxious Depression • Chronic Anxious Depression • Depression with Somatic Symptoms • Treatment Resistant Depression • Bipolar Depression
    9. 9. 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.
    10. 10. 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.
    11. 11. • 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.
    12. 12. 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
    13. 13. Treatment-Resistant Depression 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 .
    14. 14. 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.
    15. 15. USEFUL TERMS • DEPRESSED MOOD • DEPRESSIVE SYNDROME • DEPRESSIVE ILLNESS
    16. 16. 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.
    17. 17. 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.
    18. 18. 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)
    19. 19. 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
    20. 20. 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
    21. 21. PATHWAYS TO CARE Goldberg & 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
    22. 22. 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.
    23. 23. 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.
    24. 24. 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 .
    25. 25. 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.
    26. 26. PERCENTAGE OF MAJOR DIAGNOSTIC CATEGORIES DURING FOUR YEARS IN IOP Journal of CPSP (2001) Fig.3 Percentage of major diagnostic categories. overall% Males Females 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Scizophr Depressi Bipolar Mania Drug Personal Depende ity OCD Conversi enia on on 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%
    27. 27. Postnatal depression in developing countries Goa, India Prevalence 23% Patel et al., 2002. American Journal of Psychiatry; 159: 43-47 Dubai, United Arab Emirites Prevalence 15.8% Ghubash & Abou-Saleh, 1997. British Journal of Psychiatry; 171: 65-68 Khayelitsha, South Africa Prevalence 34.7% Cooper et al., 1999. British Journal of Psychiatry; 175: 554-58
    28. 28. Antenatal and Postnatal depression in a rural community Rawalpindi, Pakistan Rahman, 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
    29. 29. 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
    30. 30. Conclusion Maternal depression is a major determinant of infant growth and well-being
    31. 31. MEAN DURATION OF STAY IN DAYS FOR MAJOR DIAGNOSTIC CATEGORIES. 7.6 15.93 Depression Schizophrenia 18.94 Hypomania 18.3 19.3 Bipolar Drug Dependence
    32. 32. 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
    33. 33. Looking Up: Improving the Management of Depression
    34. 34. Depression Is Underdiagnosed and Undertreated Medical Outcomes Study 100 80 60 % of Depressed Patients 40 22.7 13.7 20 0 Receiving Antidepressant Wells KB et al. Am J Psychiatry. 1994;151:694-700. Receiving Adequate Dose
    35. 35. Depression Is a Chronic Illness 100% 50% 80% 90% 50% Probability of Recurrent Episodes 0% After 1 Episode After 3 Episodes Kupfer DJ. J Clin Psychiatry. 1991;52:(suppl 5):28-34. After 2 Episodes
    36. 36. Defining outcomes and phases of treatment Remission Relapse Euthymia Syndrome Continuation (4-9 months) Maintenance (>1 year) Relapse on ssi gr e er Pro ord dis to Symptoms Recurrence Treatment phases Response Acute (6-12 weeks) TIME Adapted from Kupfer. J Clin Psychiatry 1991; 52 (Suppl 5): 28-34.
    37. 37. 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
    38. 38. 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 • • • • •
    39. 39. 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 (?)
    40. 40. 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
    41. 41. 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
    42. 42. OTHER THERAPIES FOR DEPRESSION • Psychotherapy • Electroconvulsive therapy
    43. 43. 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
    44. 44. 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
    45. 45. 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
    46. 46. 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
    47. 47. 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
    48. 48. 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
    49. 49. 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.
    50. 50. 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.
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