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Depressive Disorders.pdf

  1. 1. Depressive Disorders Saleh Al-Khalid R2 Supervised By Dr. Nashwa Banani Special thanks to Dr. Ahmad Al-Saleh
  2. 2. Outline  Approach to Patient with Depressive Symptoms  Differentiate between types of depression according to the DSM ◦ Major depression ◦ Dysthymia ◦ Bipolar ◦ Cyclothymia ◦ Adjustment ◦ Grief ◦ Acute stress disorder ◦ Post traumatic stress disorder  Each disease: Prevalence in PHC, Management  Lest Treatment Option  When to Refer to psychiatry
  3. 3. Clinical case problem:  A 28 year old man comes to the office with his wife because he has been "feeling tired” during the past 4 months. He says he always feels “run down” but also notes that he does not sleep well. He says he is able to fall asleep when he goes to bed at 10 PM ,but he wakes up at 3 AM and is unable to get back to sleep, he notes that he often has trouble with focus and concentration  he lacks the energy to finish his tasks at home. His appetite has decreased and you note a 10 pound weight loss since his last visit 6 months ago he denies fever, nausea, vomiting, or night sweat. He has no other medical problems and any other medication, his physical examination is normal
  4. 4. What is most likely diagnosis ? A. adjustment disorder with depressed mood B.GAD C.MDD D. mood disorder caused by a general medical condition. E. dysthymic disorder
  5. 5. Interviewing Psychiatric Patients in PHC
  6. 6. Goal of Psychiatric Assessment  To make a diagnosis  To describe patient’s condition  To identify psychiatric emergencies  To find out the predisposing and primary cause of behavior  To plan an interventions
  7. 7. Components of Psychiatric Assessment  Psychiatric History  Mental Status Examination  Physical Examination  Investigations
  8. 8. Psychiatric History  Source & Reliability of Information  Identification Data  Chief Complaints  History of Present Illness  Past Psychiatric History  Past Medical History  Medications & Allergy  Family Psychiatric History  Personal & Social History
  9. 9. Identification Data  Name  Age  Sex  Marital Status  Children  Living Arrangement  Work
  10. 10. Chief Complaint
  11. 11. History of Present Illness  Onset / Duration  Depressive symptoms ◦ 5/9 symptoms (M or I is required) for two weeks  M mood (depressed)  S sleep disturbance  I interest (loss)  G guilt  E energy (decreased)  C concentration difficulties  A appetite/weight changes  P psychomotor abnormalities  S suicidal ideation
  12. 12. History of Present Illness  Suicide assessment  Bipolar symptoms  Psychotic symptoms  Anxiety symptoms  Recent stressors
  13. 13. Past Psychiatric History  Previous Visits to Mental Health Professionals  Previous Diagnoses  Psychiatric Hospitalizations  Suicide in the past
  14. 14. Past Medical History  Medical Diseases ◦ Epilepsy ◦ Head injury ◦ Hypothyroidism ◦ Anemia  Surgeries
  15. 15. Medications & Allergy  Psychiatric Medications  Other Medications  Over the counter medications  Herbal Remedies  Allergy
  16. 16. Family Psychiatric History  Psychiatric Illnesses in the Family  Substances in the Family  Suicide in the Family
  17. 17. Personal & Social History  Perinatal history  Place of birth  Place of upbringing  Childhood  Parents (age, job, personality, relationship)  Siblings (numbers, brothers & sisters, rank, relationship)
  18. 18. Personal & Social History  Abuse (emotional, physical, and sexual)  Educational history  Occupational history (current and past jobs)  Sexual & Marital history ◦ Spouse (age, personality, relationship) ◦ Serious relationships
  19. 19. Personal & Social History  Caffeine consumption  Cigarettes  Alcohol and street drugs use  Criminal history  Interpersonal relationship  Activity level
  20. 20. Mental Status Examination Components  Appearance  Behaviors  Attitude  Speech  Mood  Affect  Thought Process (Thought Form)  Thought Content  Perceptual Disturbance  Cognition & Sensorium  Insight and Judgment
  21. 21. Appearance  Actual & Apparent Age  Hygiene & Grooming  Body Habitus  Physical Abnormalities  Jewelry & Cosmetic Use  Tattoo and Piercing
  22. 22. Behaviors  Patient’s motor behavior ◦ Restlessness ◦ Fidgety movements ◦ Psychomotor Agitation ◦ Psychomotor Retardation ◦ Compulsions, tics
  23. 23. Attitude  Toward the examiner ◦ Cooperative ◦ Seductive ◦ Guarded ◦ Childish  Eye contact ◦ Good eye contact (Appropriate) ◦ Limited eye contact ◦ Poor eye contact
  24. 24. Speech  Fluent  Stuttering  Tone  Rate ◦ Pressured speech ◦ Slow speech  Speech latency
  25. 25. Mood  Mood: Subjective emotional state ◦ “Depressed”/”down” ◦ “Happy” ◦ “Angry” ◦ “Anxious”
  26. 26. Affect  Affect: Objective Emotional State ◦ Adequate ◦ Constricted ◦ Dramatic ◦ Blunted ◦ Flat
  27. 27. Thought Process  Organized, goal-directed  Disorganized ◦ Circumstantiality (wander, but go back to the point) ◦ Tangentiality (wander, but doesn’t go back) ◦ Flight of Ideas (fast, connection between ideas) ◦ Loose Association (no connection between ideas) ◦ Thought Blocking (sudden stopping in speech) ◦ “Word Salad” (random intact words) ◦ Incoherent (words meaningless)
  28. 28. Thought Content  Obsessions  Overvalued Ideas  Delusions ◦ Paranoid/Persecutory ◦ Grandiose ◦ Religious ◦ Somatic  Suicidal/Homicidal Thoughts
  29. 29. Perceptual Disturbances  Illusion: Misperception of an existing stimulus  Hallucination: Perception without real stimulus ◦ Auditory ◦ Visual ◦ Tactile ◦ Olfactory ◦ Gustatory
  30. 30. Sensorium & Cognition  Alertness / Level of Consciousness: ◦ (e.g. alert/awake, clouding of consciousness)  Orientation (Time, Place, and Person)  Concentration and Attention ◦ (Serial 7’s, Spell “WORLD” backwards)  Memory (Immediate, recent, remote)
  31. 31. Insight and Judgment  Insight: ◦ Awareness of one’s illness ◦ Awareness of one’s illness impact on self and others ◦ Acknowledgment of the need of treatment  Full Insight  Partial Insight  Impaired/No Insight
  32. 32. Insight and Judgment  Judgment: ◦ Ability to understand and communicate ideas ◦ Intact cognitive abilities ◦ Control over impulses  Intact Judgment  Limited Judgment  Impaired Judgment
  33. 33. What is Mental Illness?  Definition of Mental Disorder (DSM-V): ◦ A health condition characterized by significant dysfunction in an individual’s cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning  Include various affective, cognitive, behavioral and perceptual abnormalities
  34. 34. Myths about Mental Illness  Mental illness only affect few people ◦ Fact: Mental illness is very common  The mentally ill are violent and dangerous ◦ Fact: Most are victims of violence, and they are more likely to harm themselves than they are to hurt other people  People with mental illness should be kept in hospital ◦ Fact: With appropriate treatment and support, they can live successfully in the community
  35. 35. Stigmatization  Only about 35% of people with diagnosable disorders seek treatment  The single most common barrier to seeking treatment is Shame  Why does stigma surround mental illness?  Stigma leads to: ◦ Discrimination ◦ Fears, mistrust, and isolation ◦ Not seeking help
  36. 36. Classification of Mental Disorders  Mental Disorders are diagnosed based on criteria listed in Diagnostic Manuals  1. Diagnostic and Statistical Manual of Mental Disorders (DSM) ◦ Developed by the American Psychiatric Association (APA) ◦ Used in North America  2. International Classification of Diseases (ICD) ◦ Developed by the World Health Organization (WHO) ◦ Used in Europe and many parts of the world
  37. 37. Classification of Mental Illness  Schizophrenia Spectrum & other Psychotic Disorders  Depressive Disorders  Bipolar & Related Disorders  Anxiety Disorders  Obsessive-Compulsive & Related Disorders  Trauma & Stressor Related Disorders  Dissociative Disorders  Somatic Symptom & Related Disorders  Feeding & Eating Disorders  Elimination Disorders
  38. 38. Classification of Mental Illness  Sleep-Wake Disorders  Sexual Dysfunctions  Disruptive, Impulse-Control & Conduct Disorders  Substance-Related and Addictive Disorders  Personality Disorders  Neurocognitive Disorders  Neurodevelopmental Disorders  Paraphilic Disorders
  39. 39. Depressive Disorders  Major Depressive Disorder ◦ One or more Major Depressive Episode  Dysthymic Disorder (Persistent Depressive Disorder)  Premenstrual Dysphoric Disorder
  40. 40. Bipolar Disorders  Bipolar I Disorder ◦ ≥ Manic Episode  Bipolar II Disorder ◦ ≥ Hypomanic Episode + ≥ MDE  Cyclothymic Disorder
  41. 41. Anxiety Disorders  Separation Anxiety Disorder  Specific Phobia (Simple Phobia)  Social Anxiety Disorder (Social Phobia)  Generalized Anxiety Disorder  Panic Disorder  Agoraphobia
  42. 42. Schizophrenia Spectrum & Other Psychotic Disorders  Brief Psychotic Disorder: ◦ Positive psychotic symptoms last from one day to one month with full return to premorbid level of functioning  Schizophreniform Disorder: ◦ Psychotic symptoms last from one month to 6 moths with full return to premorbid level of functioning  Schizophrenia: ◦ Psychotic symptoms last more than 6 months, chronic illness
  43. 43. Schizophrenia Spectrum & Other Psychotic Disorders  Schizoaffective Disorder: ◦ Manic Episode or Major Depressive Episode together with psychotic symptoms  Delusional Disorder: ◦ One or more delusions, no prominent hallucinations, symptoms are encapsulated, no significant impairment in function, behavior is not obviously bizarre or odd
  44. 44. Personality Disorders  Cluster A: ◦ Paranoid, Schizoid, Schizotypal  Cluster B: ◦ Antisocial, Borderline, Histrionic, Narcissistic  Cluster C: ◦ Avoidant, Dependent, Obsessive-Compulsive
  45. 45. Violence and Mental Health  People and Media always link mental illness to violence and criminality  100 times more likely to kill themselves than another person  Predictors of violence with mental illness: ◦ Previous violence ◦ Substance abuse ◦ Personality disorders (Antisocial and Borderline PD) ◦ Paranoid Psychosis
  46. 46. Victimization  People with major mental illness are more likely to become victims of emotional and physical abuse,  WHY?  Kelly & McKenna (1997) surveyed one hundred people with mental health problems: ◦ 15 had stones thrown at windows ◦ 14 were verbally abused ◦ 5 had offensive graffiti ◦ 12 harassed outside home
  47. 47. Suicide
  48. 48. Definitions  Suicide: the act of intentionally ending one's own life  Suicide Ideation: thoughts of engaging in behavior intended to end one's life  Suicide Plan: the formulation of a specific method through which one intends to die  Suicide Attempt: engagement in potentially self- injurious behavior in which there is at least some intent to die  Non-suicidal Self-injury: self-injury in which a person has no intent to die
  49. 49. Some Facts About Suicide  8th leading cause of death in USA  3rd leading cause of death in young people (15-24 years old) in USA  Takes the lives of nearly 30,000 Americans every year  Highest rate in white men over 65  50-75% seek help before suicide
  50. 50. Global Suicide Rates (2008)
  51. 51. Suicide Risk Factors  Psychiatric Illness ◦ 90% of suicide had psychiatric illness ◦ 15% of those who are clinically depressed eventually die by suicide ◦ Mood disorders, schizophrenia, and substance abuse ◦ Alcoholism associated with up to half of all suicides ◦ 15% of alcohol dependent patients commit suicide  Age ◦ 15-24, > 45  Sex ◦ 4 male completed suicides for every female completed suicide
  52. 52. Suicide Risk Factors  Marital Status ◦ Socially isolated (Divorced, widowed, unmarried)  Employment ◦ Unemployed  Religion ◦ Atheist have a higher risk  Physical Health ◦ Patients with chronic pain, burns, HIV, cancers  Skills and Personality Character ◦ Impulsivity, poor problem solving, and poor coping with stress
  53. 53. SAD PERSON Scale  S Sex (Male)  A Age (<20 or >44)  D Depression  P Previous Attempts  E ETOH abuse  R Rational thinking loss  S Suicide in the family / Social support lacking  O Organized plan  N No spouse, no significant other  S Sickness (Chronic, Debilitating, and Severe)
  54. 54. Suicide Prevention  Education and public awareness  Decrease social isolation  Identify mental illness, substance abuse, victimization, and rejection  Treatment of mental illness  Secure or remove firearms  Decrease barriers around help seeking  Mental health crisis line  Psychiatric Hospitalization
  55. 55. Causes of Mental Illness  Biological factors  Psychological factors  Environmental/Social factors  Interaction between other factors
  56. 56. Biological Factors  Biochemistry  Genetics  Brain defect or injury  Infections  Perinatal injury  Substance abuse  Poor nutrition / Toxins
  57. 57. Psychological Factors  Traumatic experience  Important early loss  Learned behaviors  Attachment styles  Parenting styles  Poor coping skills  Personality traits
  58. 58. Environmental/Social Factors  Death or divorce  Dysfunctional family life  Social isolation  Social or cultural expectations
  59. 59. Depressive Disorders
  60. 60. Depression  It is NOT something to be ashamed of  It is NOT a sign of weakness  No one with depression can just “Snap Out of It”  Depression is an illness that involves thoughts, mood, and the body  It impacts the way a person functions socially, academically, and at work
  61. 61. Major Depressive Disorder (MDD)  Unipolar Depression  Single or Recurrent  Symptoms cause marked distress or impairment in social, occupational, or other important areas of functioning.  Symptoms are not due to a substance or a general medical condition  NO Hx. of mania, or hypomania
  62. 62. 5/9 symptoms (M or I is required) for two weeks  M mood (depressed)  S sleep disturbance  I interest (loss)  G guilt  E energy (decreased)  C concentration difficulties  A appetite/weight changes  P psychomotor abnormalities  S suicidal ideation
  63. 63. Persistent Depressive Disorder (Dysthymia)  For at least 2 years, presence of Depressed mood +  2/6 for most of the day, more days than not ◦ A Appetite change (Increased or decreased) ◦ C Concentration difficulties ◦ H Hopelessness ◦ E Energy (low) ◦ S Sleep disturbance (Insomnia or Hypersomnia) ◦ S Self esteem (low)  No more than 2 months w/o symptoms
  64. 64. Premenstrual Dysphoric Disorder (PMDD)  5 symptoms present in the final week before the onset of menses, and improve after the onset of menses in the majority of menstrual cycles  ≥ 1 of 4: ◦ Marked affective liability ◦ Marked irritability ◦ Marked depressed mood, or feeling hopelessness ◦ Marked anxiety  Plus
  65. 65. Premenstrual Dysphoric Disorder  ≥ 1 of 7: ◦ Interest (decreased) ◦ Concentration difficulties ◦ Energy (Marked decreased) ◦ Appetite change (Marked increased or decreased) ◦ Sleep disturbance (Insomnia or Hypersomnia) ◦ Sense of being overwhelmed or out of control ◦ Physical sx. (breast tenderness, joint or muscle pain, bloating)  Symptoms cause significant distress or interference with work, school, social activities , or relationship with others  Symptoms are not due to a substance or a general medical  condition
  66. 66. Medical Disorders Associated With Depression  Hypothyroidism  Cushing’s Disease  Diabetes  Myocardial Infarction  Cerebrovascular Accident  Parkinson’s Disease, Huntington's disease, Multiple Sclerosis, Epilepsy  Cancers  Autoimmune Disorders  Nutritional Deficiencies  HIV  Chronic Pain
  67. 67. Substances Associated with Depression  Alcohol  CNS Depressants (e.g. Benzodiazepines)  Cocaine, Opiates, Cannabis  Anabolic Steroids (e.g. Testosterone)  Interferon  Steroids and Hormones  Cardiovascular and Antihypertensive medications  Antimicrobials and Antimalarial drugs  Phenytoin  Cimetidine
  68. 68. Depression Subtypes  With Anxious Distress  With Mixed Features  With Atypical Features  With Psychotic Features  With Peripartum Onset  With Seasonal Pattern
  69. 69. Etiology  Neurotransmitter Model  Genetic Transmission Model  Stress - Diathesis Model  Sleep Disturbance Model  Psychological Models
  70. 70. Epidemiology  Affects over 350 millions people worldwide (WHO)  Affects all genders, ages, and backgrounds  Prevalence  Males: 5-12%  Females: 10-25%  First degree relatives have 2 to 3 times the risk of developing depression  More prevalent in: ◦ Females (2:1) ◦ Pregnant/Postpartum women ◦ Divorced/Widowed individuals/Low income
  71. 71. Prevalence in KSA  KSA study (Al- Faris) 2012: ◦ Mental disorders in patients attending PHC = 30 – 46%. ◦ Men: 5 – 12% ◦ Women: 10 – 25% ( Cause ? ) ◦ The highest incidence = 25 – 34 years.
  72. 72. Why do we Treat Depression  WHO ranked depression as 4th disabling illness , 2nd by 2020  Depression increases risk for:  Heart attack  Stroke  Worsen diabetes  Chronic disease  Increases utilization of medical services (e.g., emergency room visits, hospitalization)  Increase risk of suicide (40-60% of completed suicide involve patients with depression)
  73. 73. The Global Burden of Disease  1990  Lower Respiratory  Infections  Diarrheal Diseases  Perinatal conditions  Depression  Heart Diseases  Cerebrovascular D/O  2020  Heart Diseases  Depression  Traffic accidents  Cerebrovascular D/O  COPD  Lower Respiratory  Infections
  74. 74. Course and Prognosis  Major cause of morbidity and disability  Risk of having another episode: ◦ ≥ 60% if one previous episode ◦ ≥ 70% if two previous episodes ◦ ≥ 90% if three previous episodes ◦ 5%-10% will go on to develop Bipolar Disorder ◦ Up to 15% of patients with severe MDD will kill themselves
  75. 75. History  Review Depressive symptoms  Assess suicidality  Review other psychiatric disorders (Bipolar, Psychosis)  Stressors  Past psych Hx including prior treatments and response  Medical Hx  Medications  Family Psych Hx  Social & Personal Hx  Don’t forget to ask about ETOH & drugs abuse  Current support system
  76. 76. Workup  CBC  Electrolytes & Renal Function  Liver Function Test  Thyroid Function Test  B12, Folate
  77. 77. Therapeutic Approaches Biopsychosocial  Always assess for SUICIDE  Education and support  Psychotherapies  Cognitive  Group  Grief Work  Family involvement  Medications (SSRIs, SNRIs, TCAs..)  Brain Stimulation (ECT, TMS)
  78. 78. Treatment Goals Treatment Reduce/Remove Signs, Symptoms Restore Role/ Function Minimize Relapse/ Recurrence Risk
  79. 79. Treatment  Medications: ◦ Selective serotonin reuptake inhibitors (SSRIs) ◦ Tricyclic antidepressants (TCAs) ◦ Monoamine oxidase inhibitors (MAOIs) ◦ Others: Venlafaxine, Mirtazapine, Bupropion  Psychotherapy: ◦ Cognitive Behavioral Therapy (CBT) ◦ Interpersonal Therapy (IPT)  Others: ◦ Electroconvulsive Therapy (ECT) ◦ Transcranial Magnetic Stimulation (TMS) ◦ Light Therapy – for Seasonal depression
  80. 80. Choice of Antidepressant?  Cost  Patient’s preference  Previous response/Family history of response  Depression Subtype  Side effects  Comorbidity (Medical/Psychiatric)  Potential for drug-drug interactions
  81. 81. Tricyclic antidepressants  E.g.: Amitriptyline, imipramine, amoxapine.  MOA: inhibit the re-uptake of monoamine neurotransmitter (serotonin and NE) into the presynaptic neuron  Side effects: ◦ anticholinergic (antimuscarinic ) effects  Dry mouth, blurred vision, constipation, urinary retention. ◦ Sedation as a result of histamine blockade ◦ Orthostatic hypotension due to peripheral alpha 1 blockade  Elderly ◦ Lower seizure threshold seizures can be provoked ◦ Cardiac toxicity in overdose (arrhythmias, AV block) ◦ Weight gain. Appetite stimulant due to the weight gain.
  82. 82. Heterocyclic Antidepressants
  83. 83. Tricyclic Antidepressant  All TCA are equally effective.  Two groups: sedative , less sedative.  All require 2-4 weeks for clinical improvement.
  84. 84. Tricyclic Antidepressant  Sedative TCA : Amitriptaline, Doxepin, Trazodone.  Less sedative TCA : Imipramine, Nortriptyline. Usual Daily Doses:  Amitriptaline ( Elavil ) 75 – 300 mg  Doxepin ( Sinequan ) 75 – 300 mg  Imipramine ( Tofranil ) 75 – 300 mg  Nortriptyline ( Pamelor ) 50 -150 mg
  85. 85. Selective Serotonin Reuptake Inhibitors (SSRIs)  e.g. Citalopram, Fluoxetine, Paroxetine, Sertraline  MOA: reduce serotonin reuptake ( increase synaptic serotonin concentration) with less or no effect in NE reuptake.  They have a more favorable profile of unwanted effects than TCAs because of low affinity for muscarinic, histamine and alpha 1 receptor  Pharmacokinetics ◦ Citalopram, fluoxetine, sertraline have very long half-life (range 24-80 hr)  Norfluxetine (active metabolite of fluxetin) half-life = 6 days
  86. 86. Selective Serotonin Reuptake Inhibitors (SSRIs)
  87. 87. Selective Serotonin Reuptake Inhibitors (SSRIs)  Advantage : safer in overdose, little or no anticholinergic effects, little or cardiovascular effects ◦ Less sedation ◦ Less weight gain  Side effects ◦ Decrease appetite (5HT) ◦ Nausea /vomiting ◦ Insomnia ◦ Anxiety, agitation ◦ Dry mouth and constipation with paroxetine ◦ Hyponatremia ◦ Sexual dysfunction  Drug-Drug interaction ◦ The most serious is with MAOIs ◦ Fluoxetine, fluvoxamine and paroxetine inhibit CYP450 and it can increase the plasma level of drugs metabolized by this enzyme.
  88. 88. Serotonin Reuptake Inhibitor (SSRI)  Usual daily doses ◦ Fluoxetine (Prozac cap) 20 -60 mg daily. ◦ Paroxetine (Seroxat tab) 20 -50 mg daily. ◦ Fluvoxamine (Faverine tab) 100- 300 mg daily. ◦ Sertraline (Lustral tab) 50 – 200 mg
  89. 89. Dual Serotonin and Norepinephrine Reuptake Inhibitor (SNRI)  E.g. duloxetine, venlafaxine  MOA : inhibit reuptake of serotonin and NE. At a low dose they inhibit serotonin reuptake.  Low affinity to muscarinic and histamine receptors, and alpha 1 adrenoceptor.  Weak inhibitors to CYP450 enzymes  Side effects ◦ Nausea, vomiting, constipation. ◦ Insomnia, drowsiness, dizziness, confusion. ◦ Sexual dysfunction ◦ QT segment prolongation which can predispose ventricular arrhythmias.  Venlafaxine should be avoided in people at high risk of arrhythmias.
  90. 90. Monoamine oxidase inhibitors (MAOI)  Rarely used for depression.  Choice after no response to other antidepressant.  Have serious side effects.  Should be reserved for use by experts.
  91. 91. Classic (non-selective) MAO  E.g. phenelzine  MAO: nonselective blockade  Side effects: ◦ Dose-related orthostatic hypotension ◦ CNS stimulation : irritability, insomnia (give AM) ◦ Hypertensive crisis – with tyramine containing food, pressors  Headache, stiff neck, increase BP, palpitation, sweating  Effects of drug last 14 days with irreversible agents  Interactions ◦ Sympathomimetic agents ◦ SSRIs – 5HT syndrome  Shivering, sweating, ataxia, hyperactivity, fever, high BP, disorentation ◦ Diet – avoid tyramine contacting food
  92. 92. Monoamine oxidase inhibitors  Two types ◦ Classic (non-selective) MAO  E.g. phenelzine ◦ Reversible inhibitors of MAO A  E.g. Moclobemide
  93. 93. Essential Information for Patient  Medication is NOT addictive.  Medication must be taken everyday.  Improvement will build up over 2-3 weeks after starting medication.  Mild S/E may occur but usually fade in 7-10 days.
  94. 94. Essential Information for Patient  Medication should NOT be discontinued without physician knowledge.  Continue full dose for at least 4-6 months after the condition improves to prevent relapse.  Withdraw gradually, preferably over 4 weeks in weekly decrements.
  95. 95. Treatment  Response: 50% reduction of Depressive symptoms Remission: 2/12 completely free of symptoms  Goal of Treatment: to achieve Remission  Untreated residual Symptoms:  Increase risk of relapse  More severe and chronic course of illness
  96. 96. Follow up Visit  Monitor with frequent contacts during initial period of acute phase therapy. First contact within 2 weeks.  Reassess at 4 – 6 weeks to include compliance with medications.  If partial response – continue treatment with frequent contacts with a goal of having 3 visits during first 12 weeks of acute phase therapy.  Continue Antidepressant therapy for 4 – 9 months.
  97. 97. Follow up Visit  If no response after 6 weeks or partial response after12 weeks change dose, medication, use adjunctive therapy counseling, psychotherapy, support groups.  Long term maintenance therapy for several months required in patients suffer from relapse, sever symptoms return within 6 month following remission, or pt . With H/O 3 or more episodes.
  98. 98. Referral:  Unconfirmed diagnosis.  Psychotic major depression.  Failure or partial response to treatment.  Substance abuse.  High suicidal risk.  Refuse medication or treatment.
  99. 99. Risk Factors for Treatment Failure  Inaccurate Diagnosis  Inadequate Medication Dose or Inadequate Treatment Duration  Poor Treatment Compliance  Comorbid Substance abuse  Comorbid Psychiatric conditions  Comorbid Medical conditions
  100. 100. SSRIs Discontinuation Syndrome  Flu-like symptoms: dizziness, vertigo, and nausea  Jolt-like bursts several times throughout the day  Occur within 1-3 days after abrupt DC of the SSRI  Most prominent with Paroxetine  Treatment: ◦ Taper the SSRI slowly or start another SSRI
  101. 101. Serotonin Syndrome  Caused by excessive enhancement of serotonin neurotransmission when 2 or more different serotonergic agents are combined  Triad of: ◦ Autonomic instability: fever, diaphoresis, BP instability ◦ Mental status changes: hallucinations, confusion, delirium ◦ Physical findings: tremors, myoclonus, hypertonicity, hyperreflexia
  102. 102.  Onset range from hours to days  Serious complications: seizures, hyperthermia, respiratory failure and death  Treatment: ◦ DC Serotonergic Agents ◦ Antipyretics ◦ Muscle relaxants ◦ Serotonin antagonist: Cyproheptadine
  103. 103. Electroconvulsive therapy (ECT)  Up to 80% - 90 % remission rate with 8-12 treatments; less in Tx-resistant depression  Up to 50%-80% relapse within 6 months  Side effects: transient cognitive problems, headaches, fatigue  May be first line for certain populations (e.g., medically ill, intensely suicidal, catatonic)
  104. 104. Bipolar Disorders
  105. 105. Bipolar Disorders  Bipolar I Disorder  Bipolar II Disorder  Cyclothymic Disorder  Substance/Medication – Induced Bipolar & Related Disorder  Bipolar & Related Disorder due to Medical Condition
  106. 106. Bipolar I Disorder  Manic Episode + Depressive Episode
  107. 107. Manic Episode (ME)  Mood disturbance = Abnormally and persistently elevated, expansive, or irritable mood ≥ 1 week (or less if treated)  Euphoria + ≥ 3 symptoms or irritable + ≥ 4 symptoms: ◦ § Grandiosity or inflated self-esteem ◦ § Increased Goal Directed Activity ◦ § Decreased Judgment (Impulsivity) ◦ § Distractibility ◦ § Irritability ◦ § Need for sleep decreased ◦ § Euphoria ◦ § Speedy Thoughts ◦ § Speedy Talk  Marked social/occupational impairment or require hospitalization or presence of psychotic symptoms  Not due to drugs or medical conditions
  108. 108. Bipolar II Disorder  Hypomania + Major Depressive Episode
  109. 109. Hypomanic Episode (HE)  Mood disturbance = Abnormally and persistently elevated, expansive, or irritable mood for ≥ 4 days (or less if treated)  Symptoms similar to ME, but: ◦ For 4 days ◦ No Psychosis ◦ No severe impairment ◦ No Hospitalization  Not due to drugs or medical conditions
  110. 110. Major Depressive Episode  5/9 symptoms (M or I is required) for two weeks ◦ M mood (depressed) ◦ S sleep disturbance ◦ I interest (loss) ◦ G guilt ◦ E energy (decreased) ◦ C concentration difficulties ◦ A appetite/weight changes ◦ P psychomotor abnormalities ◦ S suicidal ideation  Symptoms cause marked distress or impairment in social, occupational, or other important areas of functioning  Symptoms are not due to a substance or a general medical condition
  111. 111. Bipolar & Related Disorders  Bipolar I Disorder ◦ ≥ Manic Episode  Bipolar II Disorder ◦ ≥ Hypomanic Episode + ≥ MDE ◦ Never been a ME  Cyclothymic Disorder
  112. 112. Cyclothymic Disorder (Cyclothymia)  Milder form of bipolar  More chronic form
  113. 113. Cyclothymic Disorder (Cyclothymia):  For at least 2 years:  Numerous periods with Hypomanic sx (Not meeting HE)  Numerous periods with Depressive sx (Not meeting MDE)  Periods persisted for at least half the time and No more than 2 months w/o symptoms  No history of MDE, ME, or HE  Symptoms are not due to a substance or a general medical condition  Symptoms cause distress or impairment in social, occupational, or other important areas of functioning
  114. 114. Bipolar Subtypes  With Anxious Distress  With Mixed Features  With Rapid Cycling  With Atypical Features  With Psychotic Features  With Peripartum Onset  With Seasonal Pattern
  115. 115. Bipolar with Rapid Cycling  Rapid Cycling ◦ > 4 mood episodes/year
  116. 116. Bipolar Episodes
  117. 117. Medical Disorders Associated With Bipolar  Hyperthyroidism  Cushing’s Disease  CVA ◦ Right side lesion can cause mania ◦ Left side can cause depression  Multiple Sclerosis  CNS tumors  CNS infections (Meningitis, Neurosyphilis)  SLE  HIV
  118. 118. Substances Associated with Bipolar  Alcohol  Cocaine, hallucinogens  Methylphenidate ◦ ADHD  Interferon ◦ Hip. C  Ionizide ◦ TB  Digoxin ◦ HF  Glucocorticoids  Disulfiram ◦ Anti abuse
  119. 119.  Genetic factors  37% MDD (Sullivan et al., 2000)  93% Bipolar Disorder (Kieseppa et al., 2004)
  120. 120. Epidemiology  Bipolar I disorder ◦ Prevalence:1% of general population ◦ M=F  Bipolar II disorder: ◦ Prevalence: 0.3 – 2% of general population ◦ F>M (3:1)  Average age of onset in 20s
  121. 121. Negative Prognostic Factors  Rapid cycling pattern  Increasing frequency of bipolar episodes  Psychotic symptoms during ME  Severe index episodes  Active substance abuse  Male gender  Onset at young age
  122. 122. Treatment  § Consider hospitalization esp. if the patient is  experiencing manic episode  § Mood Stabilizers: ◦ § Lithium ◦ § Valproic acid (Depakene) ◦ § Carbamazapine (Tegretol) ◦ § Lamotrigine (Lamictal) for Bipolar depression ◦ § Gabapentin (Neurontin) ◦ § Topiramate (Topamax)
  123. 123. Treatment  Antipsychotic: ◦ Quetiapine (Seroquel) ◦ Olanzapine (Zyprexa ) ◦ Risperidone (Risperdal) ◦ Aripiprazole (Abilify) ◦ Clozapine (Clozaril)  Antidepressants: ◦ Used with mood stabilizers for Bipolar Depression  Benzodiazepines: ◦ Used during acute mania
  124. 124. Treatment  Electroconvulsive Therapy: ◦ Effective and rapid response ◦ Effective in both depressive and manic phases
  125. 125. Lithium  Effective in: ◦ Manic episode ◦ Depressive episode ◦ Maintenance  Side effects profile affects compliance to Li  Li lowers the elevated glutamate neurotransmitter  Slow effect in treating manic episode (14 days)
  126. 126. Lithium Side Effects  Hematological: leukocytosis, leukopenia, anemia  GI: nausea, vomiting, diarrhea, metallic taste  Endocrine: Hypothyroidism (34%), diffuse non toxic Goiter, Hyperparathyoidism  Renal: Polyuria, Polydipsia, Nephrogenic DI, Interstitial fibrosis, tubular atrophy, Glomerular sclerosis  Cardiac: bradycardia, benign T-wave changes (flattening or inversion) and QRS widening  CNS: sedation, lethargy, cognitive dullness
  127. 127. Lithium Toxicity  Early signs: nausea, vomiting, diarrhea, fine hand tremors  Late signs: lethargy, nystagmus, blurred vision, coarse hand tremors, increased tendon reflexes, ataxia, altered mental status, and confusion  Cardiac arrhythmia, seizures, and coma can follow  Death in 10-15% of significant toxicity  Survivors may have permanent neurological / renal damage
  128. 128. Treatment of Li Toxicity  DC Lithium  May require ICU admission  Cardiac monitoring  Gastric lavage/aspiration  Maintenance of hydration  Treatment of arrhythmia  Treatment of electrolyte imbalance  Hemodialysis
  129. 129. VERY IMPORTANT High Recurrence
  130. 130. . Adjustment D/O • Develops in response to a stressor (w/in 3mos) • Terminates w/in 6mos of the end of the original precipitating stressor • Clinically significant b/c: •There is marked distress out of proportion to the severity of the stressor •Or there is significant impairment
  131. 131. Summery
  132. 132. Quiz:  You have diagnosed a 30-year-old woman with depression. She is concerned that medical treatment may cause sexual dysfunction. In order to avoid sexual side-effects, which antidepressant would be the best choice?  Amitriptyline  Paroxetine  Citalopram  Sertraline  Bupropion
  133. 133. Quiz :  Which of the following factors associated with dysthmic disorder ? A. Substance abuse. B. Sleep disturbance. C. Mania. D. Myasthenia gravis E. Flight of idea.
  134. 134. Quiz:  “ atypical “ depression includes all of the following features except: A. Paralysis B. Panic attack C. Long standing pattern on interpersonal rejection D. Hypersomnia E. Anorexia
  135. 135. Quiz :  Which of the following statement is true regarding the diagnosis of major depressive disorder?  There is virtually always a clear precipitating factor.  Symptoms must present for 2 weeks, with a clear change baseline status.  Both a depressed mood and diminished interest in pleasurable activities are required  The individual is more likely to evidence psychomotor agitation than psychomotor retardation.  Difficulty getting to sleep is a common complaint
  136. 136. References  DSM-V  ICD-10  BMJ  DynaMed Plus  AAFP  American Psychiatric Association  Pocket handbook of clinical psychiatry -kaplan.  Primary care Medicine – Goroll.  Text book of Family practice – Rackel.  www.who.org  www.smj.org.sa  www.aafp.org  www.ncbi.nlm.nih.gov/PubMed  www.psych.org
  137. 137.  Thank you for listening  Hope you learned something or new thing

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