Depression is the leading cause of disability world wide and is a major contributor to the overall global burden of diseases .At its worst depression can cause suicide . There are effective psychological and pharmacological treatments for depression

1. ASSESSMENT AND MANAGEMENT OF DEPRESSION
DR OGECHUKWU MBANU
FAMILY MEDICINE DEPARTMENT
AKTH KANO
24 / 10 / 2018

2. OUTLINE
•Introduction
•Epidemiology
•ICD – 10
•Aetiology
•Risk factors
•Depression in bipolar
depression
•Endogenous VS Reactive
depression
•Presentation at the GOPD
•History and examination
•Co – morbidities
•Peripartum depression
•Screening tests
•Laboratory investigations
•Management strategies
•Types of treatment
•Prognosis
•conclusion

3. INTRODUCTION
• Mental health disorder characterized by persistent low mood , loss of
interest and pleasure in daily activities ,loss of energy ,causing significant
impairment in daily life
• `Deprimere ‘ (latin) meaning pressed down
• Hippocrates used the term` melancholia ‘ – Greek for black bile
• Emil Kraepelin : `Depressive states’ as part of `manic – depressive psychosis’
• Kurt Schneider :`endogenous (melancholic) and reactive (neurotic) types
• Can be unipolar depression or part of other disorders such as BAD
• Theme of world health day 2017 was depression – title was
`` depression ,lets talk “(7th April)

4. EPIDEMIOLOGY
• Lifetime prevalence is about 15%
• There is an annual incidence of about 5%
• Average age of onset is about 30 years
• Peak age groups of onset : 30 – 44years and 18 – 29years
• About 5 to 10 % of patients with untreated / inadequately treated
unipolar depression commit suicide
• More than 1.5 million cases are reported per year in Nigeria

5. EPIDEMIOLOGY
• According to WHO Proportion of global population with depression as of
2015 is about 4.4 %
• This is about 322million people living with depression in the world
• An increase of more than 18% between 2005 and 2015
• Nearly half of these in south – east Asia region and western pacific
regions
• More common in females (5.1%) than males (3.6%)
• Prevalence varies from a low 2.6% among males in the western pacific to
5.9% among females in African region

6. ICD – 10
• It is categorized under Mood [affective] disorders
• F32 Depressive episode
• F32.0 Mild depressive episode
• .00 Without somatic syndrome
• .01 With somatic syndrome
• F32.1 Moderate depressive episode
• .10 Without somatic syndrome
• .11 With somatic syndrome
•F32.2 Severe depressive episode without psychotic symptoms

7. ICD – 10 -- 2
•F32.3 Severe depressive episode with psychotic symptoms
•F32.8 Other depressive episodes
•F32.9 Depressive episode, unspecified
• F33 Recurrent depressive disorder
• F33 .0 Recurrent depressive disorder, current episode mild
• .00 Without somatic syndrome
• .01 With somatic syndrome
• F33 .1 Recurrent depressive disorder, current episode moderate
• .10 Without somatic syndrome
• .11 With somatic syndrome

8. ICD – 10 - 3
•F33.2 Recurrent depressive disorder, current episode severe
without psychotic symptoms
•F33.3 Recurrent depressive disorder, current episode severe
with psychotic symptoms
•F33.4 Recurrent depressive disorder, currently in remission
•F33.8 Other recurrent depressive disorders
•F33.9 Recurrent depressive disorder, unspecified

9. ICD – 10 - 4
• In typical depressive episodes the individual usually suffers from
• low mood
• , loss of interest and enjoyment, and
• reduced energy leading to increased fatiguability and diminished
activity
• Typical depressive episodes (mild (F32.0) , moderate (F32.1 ), and
severe (F32.2 and F32.3)), involve two or more of the typical symptoms

• A variation of 2 to 4 or more of the other common symptoms
• Then presence or absence of somatic symptoms for mild and moderate
and presence or absence of psychotic symptoms for severe episodes

10. ICD – 10 - 5
•. Other common symptoms are:
•Reduced concentration and attention;
•Reduced self-esteem and self-confidence;
•Ideas of guilt and unworthiness (even in a mild type of
episode);
•(d)bleak and pessimistic views of the future;
•(e)ideas or acts of self-harm or suicide;
•(f)disturbed sleep
•(g)diminished appetite

11. ICD – 10 - 6
• F33 - Recurrent depressive disorder
• The disorder is characterized by repeated episodes of depression as specified
in depressive episode mild (F32.0), moderate (F32.1), or severe (F32.2 and
F32.3))
• diagnosis based on current episode
• No history of independent episodes of mood elevation and overactivity that
fulfil the criteria of mania
• If required,
• the predominant type of previous episodes (mild, moderate, severe,
uncertain) may be specified
• delusions or hallucinations , specified as mood-congruent or mood
incongruent

12. ICD – 10 -- 6
•For recurrent depressive disorder – F33.0 , F 33.1 , F33.2 ,
F33.3
•the criteria for recurrent depressive disorder (F33.-) should
be fulfilled,
•the current episode should fulfil the criteria for
•Mild ,moderate ,severe depressive episodes
•With or without somatic symptoms for F33 .0 and F 33.1
•With or without psychotic symptoms for F33.3 and F
33.4
• at least two episodes should have lasted a minimum of 2
weeks and should have been separated by several months
without significant mood disturbance

13. ICD – 10 – 7
•F33.4 Recurrent depressive disorder, currently in remission
•the criteria for recurrent depressive disorder (F33.-) should
have been fulfilled in the past,
•the current state should not fulfil the criteria for depressive
episode of any degree of severity or for any other mood
disorder
•at least two episodes should have lasted a minimum of 2
weeks and should have been separated by several months
without significant mood disturbance

14. AETIOLOGY OF DEPRESSION
GENETIC FACTORS
• Complex interaction of social , psychological and biological features
• Two susceptibility loci MDD I and MDD 2 (on chromosomes 12 and 15 respectively) have
been identified
• Other potential genes are TPH2 ,HTR 3A , HTR 3B genes
• Polymorphism of the serotonin transporter (SLC6A4) gene (on chromosome 17 ) –
5HTTLP :
-- short allele homozygosity or heterozygosity is associated with increased risk of
depression ,in response to stressful life events ,than long allele homozygosity
• Genetic factor may also mediate drug response or side effects

15. AETIOLOGY OF DEPRESSION – 2
PSYCHOSOCIAL FACTORS
• Recent stressful life events –especially a loss of e.g. bereavement , loss
of job , psychological trauma
• Loss of parents before age 10years
• Living alone
• Lack of social support
• Chronic pain
• Alcohol and substance misuse
• Medication : steroids , antihypertensives etc
• Vascular : stroke and CAD increases risk of depression and vice versa

16. RISK FACTORS FOR DEVELOPING DEPRESSION

17. DEPRESSION IN BIPOLAR DISORDER
• Can be clinically indistinguishable from unipolar depression
• In any first episode of depression the possibility of bipolar disorder needs to be
borne in mind
• Information from family members is very important as patient with significant
depression may not be able to recall any happy memories (including hypomaniac /
maniac episodes)
• 40% of patients with bipolar disorder are initially diagnosed as unipolar depression
• Depression accounts for much of long-term disability in bipolar disorder
• Patients with bipolar disorder tend to have more ( and longer)depressive episodes
in the course of their lifetime than patients with unipolar depression

18. FEATURES POSSIBLY SUGGESTIVE OF BIPOLAR DEPRESSION
• Atypical features - e.g. increased appetite , increased sleep , possibly weight
gain
• Psychomotor retardation
• More frequent episodes
• Family history of bipolar disorder
• Lower age of onset
• Male gender ( equal gender prevalence for bipolar)
• More abrupt onset

19. ENDOGENOUS VS REACTIVE DEPRESSION
• These subtypes are no longer included in ICD 10 and DSM 5
ENDOGENOUS DEPRESSION
• Occurs spontaneously without any external stressor
• Also called `melancholic’ depression or `psychotic ‘ depression
• Characterized by prominent biological / somatic symptoms of depression
• More severe symptoms e.g. psychomotor retardation ,psychotic symptoms
• More likely to need antipsychotics / ECT

20. ENDOGENOUS VS REACTIVE DEPRESSION
REACTIVE DEPRESSION
• Depression occurring in response to a clearly identifiable external
stressor e.g. bereavement ,loss of job
• Also called neurotic depression
• Less severe
• More affective symptoms eg irritability ,anxiety , guilt etc.
• Significant overlap with `adjustment disorder ‘

21. ATYPICAL DEPRESSION
• In `typical ‘depression there is reduced sleep ,reduced appetite and weight
loss
• In `atypical’ depression there is hypersomnia , increased appetite , and
weight gain
• Other features of atypical depression includes
• Feeling of heaviness in arms legs ( LEADEN PARALYSIS)
• Excessive sensitivity to interpersonal problems ( interpersonal rejection sensitivity)
• Atypical features are commoner in seasonal affective disorder and bipolar
depression than in unipolar depression
• Atypical depression may respond better to MAOIs than to TCAs or SSRI s

22. PRESENTATION OF DEPRESSION AT THE GOPD
• Patients usually do not walk into the office and say they have ``
depression ‘’
• Doctor should have a high index of suspicion and screen as many people
as possible
Features to look out for includes :
• > 5 office visits a year
• Unexplainable symptoms
• Work and home dysfunction
• Poor follow up with treatment recommendations

23. PRESENTATION OF DEPRESSION AT THE GOPD 2
•Irritable bowel syndrome -- 15% with IBS have psychiatric co -
morbidity
•Unexplained weight gain or loss
•Sleep disturbances
•Fatigue
•Cognition complaints ,difficulty making desitions

24. HISTORY AND EXAMINATION
• Note your sources of information such as relatives ,neighbors ,referring doctor
,police etc.
• Make a note on reliability of informant
• Presenting complaints with correct durations
• History of presenting complaints : this should include amongst other things
• assessment of risks
• To self e.g. suicide
• To others
• To being abused / exploited
• Past psychiatric history

25. HISTORY AND EXAMINATION 2
• Past medical history
• Personal history – pregnancy , delivery , neonatal history , early life
experiences, education , employment , pre morbid personality ,
forensic history
• Mental state examination
• Systemic examination
• Bio – psycho – social evaluation in terms of
• Predisposing
• Precipitating
• Maintaining factors
• Finally make a Diagnosis

26. Assessing risk of suicidality
• Patients usually feel hopeless about the future
• Suicide risk may paradoxically  as the severely depressed patient just starts to
improve as he / she may now have the energy to be able to act out their plan
• Inquire about specific suicidal thoughts , intent , plans , access to weapons’
• Recent suicidal behavior
• Determine current stressors and protective factors ( reasons to live)
• Protective factors include factors like having a spouse , children, sibblings , spirituality or
religion
• Determine family history of suicide
• History of violence
• Is there imminent risk to patient or to others

27. Mental state examination
Appearance
• Unkempt , withdrawn , reduced facial expression , no eye contact
Mood
• sad. , hopelessness , helpless
Affect
• Flat , blunted ,
Speech
• Low volume voice , speaking slowly , long pauses
Cognition
• Orientation may be impaired
• Attention and concentration and memory may all be impaired

28. CO - MORBIDITIES
• Co – morbidity is common for both unipolar and Bipolar depressions
• These include :
• Anxiety disorder
• Alcohol / substance misuse
• Personality disorders
• Eating disorders
• ADHD
Physical co – morbidities include
• Thyroid dysfunction
• Migraine
• Metabolic sydrome ( in addition to that induced by antidepressants)

29. PERI - PARTUM DEPRESSION
•Perinatal period is generally defined as from onset of
pregnancy until ~ 1 year postpartum
• NOTE: DSM-5 defines perinatal onset for mood disorders as being
onset during pregnancy or within 4 weeks postpartum
•An important public health issue
•Risk of a Major Depressive Episode is up to 10% in
pregnancy,
• 15% postpartum (higher than age-matched point prevalence
in the non-pregnant population)
•Risk of bipolar disorder relapse is high in pregnancy and very
high in the postpartum period

30. PERI - PARTUM DEPRESSION – 2
• Potential Impact of untreated mood disorders on
• mother,
• baby and
• family can be profound:
• Pregnancy:
• spontaneous abortion, poor prenatal care, substance use, poor
fetal growth, preterm labour, suicide
• Postpartum:
• poor attachment/parenting, delayed infant motor, language and
cognitive development, child behavior problems,
suicide/infanticide

31. SCREENING TESTS AND SCALES

34. Interpretation of PHQ 9
Test score Depression
severity
1 to 4 minimal
5 to 9 mild
10 to 14 moderate
15 to 19 Moderately
severe
20 to 27 severe
Other screening tools include
:-
•Hamilton rating scale for
depression (HAM – D)
•Beck depression inventory
(BDI)
Mainly used in research
•Geriatric depression scale
(GDS -5 and GDS – 15 )

35. SCREENING TOOLS FOR PERIPARTUM DEPRESSION
NATIONAL INSTITUTES FOR CLINICAL EXCELLENCE
(NICE)
• During the past month, have you often
been bothered by feeling down,
depressed or hopeless?
• During the past month, have you often
been bothered by having little interest
or pleasure in doing things?
If the woman answers 'Yes' to both
questions a further question should
be asked:
• Is this something you feel you need or
want help with?
EDINBURGH POSTNATAL DEPERSSION SCALE
(EPDS)
In the past seven days:
• I have been able to laugh and see the funny side of things
• I have looked forward with enjoyment to things
• I have blamed myself unnecessarily when things went
wrong
• I have been anxious or worried for no good reason
• I have felt scared or panicky for no very good reason
• Things have been getting on top of me
• I have been so unhappy that I have had difficulty sleeping
• I have felt sad or miserable
• I have been so unhappy that I have been crying
• The thought of harming myself has occurred to me
Scored 0-30. Scores > 13 associated
with 10x likelihood that patient has
major depression

36. LABORATORY INVESTIGATIONS
•Routine tests :-
• FBC
• LFT
• E/U/CR
• TFT
• FBS
• LIPID STUDIES
•Baseline ECG
•Neuroimaging and EEG may not be done routinely

37. MANAGEMENT STRATEGIES
• Develop a treatment plan
• Form a therapeutic alliance
• Clarify the realistic and unrealistic aspects of the patients expectations
of effectiveness from the medication
• Inform patient that there other medications to choose from should the
present one not work
• Build Collaboration (``we’’ instead of ``I‘’
• Discuss possible side effects
• Plan for follow up
• Stay on medication for at least 6 months -- if possible

38. TYPES OF TREATMENT
Different types of treatment
includes:-
• Psychotherapy – for mild
depression
• Anti depressants
• ECT
• Acupuncture
• Yoga
• Exercise programmes
•Patient should be counciled
to stop alcohol
•Also to reduce coffee intake
•Psychotherapy includes
:-
•Cognitive based therapy
•Positive mood
induction, mindfulness
therapy
•Behavioral activation
•Interpersonal
psychotherapy (IPT)
•Exposure to light

39. ANTI DEPRESSANTS
Monoamine hypothesis of depression :-
•Depression is due to a deficiency of monoamines : namely
serotonin and noradrenaline
•By increasing the levels of one or both of these monoamines
depression can be managed
•This is the basis for the action of most antidepressants
•They can be classified into
1. Older or first generation antidepressants and
2. second generation antidepressants
3. Third generation antidepressants

40. ANTI DEPRESSANTS 2
1ST GENERATION
ANTIDEPRESSANTS :
• Monoamine oxidase inhibitors
(MAOIs) .
• phenelzine (Nardil) ,
tranylcypromine (pariate),
moclobemide( ludomil)
• Tricyclics antidepressants (TCAs)
• Imipramine (Tofranil)
• Amitriptyline (Elavil)
• Desipramnine (norpramin)
• Nortriptyline ( Aventyl)
• Dexapine (Adepin)
2ND GENERATION
ANTIDEPRESSANTS
• Selective serotonin reuptake
inhibitors (SSRIs) :-
• Fluoxetine (Prozac )
fluvoxamine ( luvox )
sertraline (Zoloft ) ,
paroxetine ( paxil) ,
citalopram (celexa) ,
Ecitalopram ( cilantro

41. 3rd generation antidepressants
• Atypical antidepressants
• Bupropion – an NDRI
( Wellbutrin ,forfivo XL , Aplenzin)
Bupropion under the name Zyban is
used to aid in smoking cessation
• Mirtazapine - NaSSA (Remeron )
• Reboxetine – NARI
• Trazodone – also used to treat
insomnia
• Vortrioxetine (Trintellix )
• Agomelatine
• Amoxapine ( Ascendin )
• Esketamine ( ketamine derivative)
•SNRIs :-
Desvenlafaxine (Prisca )
•Duloxetine (Cymbalta )
•Milnacipran (savella )
•Venlafaxine ( effecxor )
•Levomilnacipran (Fetzima )

42. Tricyclic antidepressants
• One of the oldest drugs , has three ring structure
• Potentiates the effect of serotonin and norepinephrine in the CNS
• Significant anticholinergic effects blocking muscarinic acetylcholine
• Antagonizes histamine and adrenergic receptors
• Main role is in treatment resistant /atypical depression
• Serotonin syndrome is a risk when given with SAMe or st john‘s
wort
• Cardiotoxic in overdose

43. Tricyclic antidepressants
•Side effects includes : -
• weight gain ,sedation ,
•Drowsiness ,memory impairment
•Impaired cognitive function
•Anticholinergic side effects includes
•Dry mouth , blurred vision ,
•Constipation , sweating
•Urinary retention

44. Monoamine oxidase inhibitors (MAOIs)
•Monoamine oxidase is an enzyme which breaks down the
neurotransmitters namely
• Dopamine
• Norepinephrine
• Epinephrine
• Serotonin
•MAOIs prevents the breakdown of these neurotransmitters
thus their activities
•It has prolonged duration of action in the post synaptic cells
•Also one of the older medications

45. Monoamine oxidase inhibitors (MAOIs) – 2
• It is associated with hypertensive crisis or `` CHEESE REACTION”
• This is due to inhibition of tyramine metabolism in the gut ( contained
in some foods e.g. cheese ,alcohol certain meats ,wine, beer,
chocolates ,etc.)
• The newer MAOIs are selective in the monoamines they block
• They don't block MAO – B found in the intestines which metabolise
tyramine
• Can be potentially fatal when taken with other antidepressants
• A time interval of about 2 weeks is needed when stopping MAOIs
before starting other drugs
• For Prozac up to 5 weeks is needed

46. Monoamine oxidase inhibitors (MAOIs) – 3
•It is hepatotoxic in overdosage
•They interact with opiods ,amphetamines ,
decongestants
•Side effects includes :-
•Hypertensive crisis , seizures ,
• serotonin syndrome , dizziness ,
•Headaches , insomnia , restlessness ,
• blurred vision , arrythmias
•Orthostatic hypotension , diarrhoea

47. Selective serotonin reuptake inhibitors
• Serotonin infuences mood
• SSRIs treat depression by inhibition of serotonin reuptake
• Appetite and nutritional intake should be monitored regularly
• Suicidal tendencies should also be monitored regularly
• Not to be taken with other SSRIs ,SAMe and st johns wort
• It is associated with weight loss so sometimes prescribed for obesity
• Side effects includes
• Serotonin syndrome , Seizures , sexual dysfunction ,
• Mood changes ,  risk of suicidal behaviors , Loss of appetite , insomnia

48. Serotonin and norepinephrine reuptake inhibitors -SNRIs
•Norepinephrine affects energy levels as well as alertness
•The drugs increase the amount of serotonin and
norepinephrine available
•Patients to avoid alcohol
•Side effects includes :-
• Serotonin sydrome , suicidal ideation, seizures ,
• Insomnia , anxiety , agitation , weight loss ,
• Sexual dysfunction , fatigue , drowsiness , loss if appetite’
• Constipation , dry mouth , dysuria , increased sweating ,
• Difficulty urinating

49. Mirtazapine -- NaSSA
• Noradrenaline and specific
serotonin – anti depressants
• They cause sedation
• Increase appetite
• Weight gain
• These effects are beneficial if
biological symptoms of
depression (insomnia , 
appetite , weght loss ) are
present
AGOMELATIN
•Agonists of MT1 / MT2
melatonin receptors
•Melatonin , secreted by the
pineal gland is important for
sleep
•Side effects includes
•Acute liver failure
•Regular LFTs are important

50. NATURAL REMEDIES
• Some have been shown to be more effective than placebos and are in
some cases as effective as fluoxetine and imipramine (Dwyer , Withtten
, and Hawrelak ,2011)
• They include :-
• St john’s wort
• Saffron stigma and petal
• Lavender
• Rodiola
• Not much study on side effects
• Not to be combined with any of the other drugs

51. PERI - PARTUM DEPRESSION – MANAGEMENT
• Begins at pre-conception counseling for women with a personal history of mental
health problems . Strategies includes
• Prevention
• Decision-making related to relapse risk, follow-up plans, psycho-education re: need for sleep
and good social support
• Treatment
• Safety Assessment
• Risk-benefit analysis: safety of treatment during pregnancy/lactation vs. risks of untreated
illness
• Options: Psychotherapy, Psychotropic Medication ,ECT(rarely done)
• SSRI or SNRI is first line treatment for moderate to severe depression( most safety
data on older SSRI/SNRIs)
• Sertraline and Paroxetine usually undetectable in serum of breastfed infants,
Others < 10% passage but no adverse events reported

52. Discontinuation syndrome
•Common with antidepressants with relatively short –
half lives eg
•Venlafaxine and paroxetine
•Unusual with anti depressants with long half – life e.g.
fluoxetine
•The shorter the half life the more severe the symptoms
•Symptoms includes : - insomnia , nausea ,
•anxiety , dizziness , paresthesia ,
• mood changes , and diarrhoea

53. SEROTONIN SYNDROME
• A result of acute spike in serotonergic transmission
• Can be caused by SSRIs alone
• More common when taken with other serotogenic drugs such as :-
• Other antidepressants
• Cocaine
• Amphetamines
• Its best to allow sufficient`` wash out ‘’ time when switching from one
antidepressant to the another especially fluoxetine(Prozac)
• Features are similar to neuroleptic malignant syndrome
• Disorientation , agitation , confusion ,
• Nausea , vomiting , diarrhoea
• Sweating hyperpyrexia , shivering ,
• Autonomic instability

54. GENERAL PRINCIPLES WHEN USING ANTIDEPRESSANTS
• Start at a low dose and increase dose gradually
• Review mental state regularly
• Monitor for side effects
• Avoid using more than one antidepressants at the same time
• Takes at least 2 to 3 weeks for the anti – depressants effect to manifest
• If improvement continue for several months
• If stable withdraw gradually to avoid ` rebound ‘ relapse
• If no improvement gradually change to another anti depressants
• If repeated relapse consider long term ( possible life long ) maintenance
treatment

55. COGNITIVE BEHAVIOR THERAPY
• How one thinks (cognition) and how one acts (behavior ) can affect how one feels
(mood)
• Certain behaviors can cause one to feel low in mood
• Negative cognitions and maladaptive behaviors can cause one to feel low in
mood
• CBT aims to help the patient correct negative cognitions and unhelpful behaviors
that maintain the depression

56. INDICATIONS FOR ECT
• Severe , life threatening depression : patient not eating or drinking
• Depressive stupor
• Severe psychotic depression e.g. post partum psychosis
• In cases of life – threatening or intolerable side effects of
psychopharmacological treatments
• Treatment resistant depression : when different antidepressants have
been tried

57. RESISTANT DEPRESSION
•Refers to depression that has not responded to at least 2
different classes of anti depressants ,given at an adequate
dosage for an adequate duration ( at least for 4 – 6 weeks)
ASSESS
•Compliance
•Alcohol or drug abuse
•Interaction with other medications (eg enzyme inducers )
•Role of physical illness eg poorly controlled pain
•Psychological / social stressors

58. RESISTANT DEPRESSION -- treatment
1. Combination strategies e.g. antidepressant  CBT
2. Augmentation of antidepressants with another drug that is
not an antidepressant e.g. antidepressant  lithium or T3 or
atypical antipsychotics
3. ECT
4. Repetitive transcranial magnetic stimulation ( r TMS)
5. Transcranial direct current stimulation (t DCS)
6. Deep brain stimulation ( DBS )
7. Vagus nerve stimulation ( VNS)
•Lithium and clozapine are known to have anti suicidal effects

59. MANAGEMENT OF BIPOLAR DEPRESSION
•The atypical antipsychotic Quetiapine may be used
•Antiepileptics such as sodium valproate or lamotrigine can be
used
•Additional anti depressant (usually SSRIs) may be needed in
some but care must be taken due to possible switch to mania /
hypomania
•ECT

60. DIFFERENTIAL DIAGNOSIS
•Endocrine disorders e.g. hypothyroidism
•Drug - related conditions e.g. cocaine abuse
•Side effects of some CNS depressants
•Infectious diseases e.g. infectious mononucleosis
•Sleep – related disorders
•Central nervous system diseases e.g. Parkinson's disease
,dementia , Multiple sclerosis , neoplastic lesions

61. PROGNOSIS
Poor prognostic factors
•Earlier age of onset
•Longer duration / increased severity of episodes
•Poor initial response to treatment
•Or treatment resistance
•Suicidal behavior
•Co – morbid anxiety / personality disorders
•Alcohol and substance abuse
•Low levels of social support and social integration

62. RISK OF RECURRANCE
•At least 50% will have a recurrence after 1st episode of
depression
•Average number of episodes per decade is about 3
•Risk of recurrence
•Greater with each successive episode
•Lower with increasing periods of recovery
•About 20% experience chronic depression (ie low levels
of depression for many years without return to previous
level of normal mood

63. CONCLUSION
•Depression is a leading cause of disability worldwide wide and is
a major contributor to the overall global burden of disease
•WHO recognizes the various forms of depression as real illness.
•At its worse depression can lead to suicide
•We should educate our patients properly about depression and
about treatment options
•REMEMBER THAT DEPRESSION IS A DISEASE ,IT IS NOT
WEAKNESS OF CHARACTER OR IMAGINATION

65. REFERENCE
•The ICD 10 Classification Of Mental And Behavioral Disorders
•Psychiatric Mental Health Medication Overview Presentation
,Accessed OCT 26 2018
•Douglas M M ,Depression Screening ,American Academy Of
Family Physicians JAN15 2012, Www.Aafp.Org/Afp
•WHO , Depression And Other Mental Disorders , Global Health
Estimates
•Treating Depression In The Primary Care Setting , Presentation
By Dr Sager
•Screening For Depression In Primary Care Presentation By Dr
Bishop And Sarah Williams

66. REFERENCE
•Dr Rajagopal , May 23 2015 ,Psychiatric Lecture : Mood Disorder
– Depression And Bipolar Disorder , Accessed SEP 30 2018
•Update On Perinatal Mood Disorders ,Presentation By William
Watson And Simone Vigod
• Depression Its Symptoms ,Causes And Treatment Presentation
By Dr Adelbert Scholtz
•Psychopharmacology Hour Accessed October 26 2018
•Dr Rajagopal Jan 21, 2015 ,Psychiatric Lecture ,Descriptive
Psychopathology; Accessed October 24 2018