Major Depressive Disorder

1. Major Depressive Disorder

3. Contents
 Introduction
 Sleep Problem
 Depression
 History
 Examination
 Treatment

4. Introduction
 Differential Diagnosis of Sleep Problem
 Major Depression
 Endocrine disorder
 Football Season

5. Depression
 A significant mental health problem that disrupts a
person's mood and adversely affects his psychosocial
and occupational functioning
 By the year 2020 major depression is projected to be
the second largest contributor to the global burden of
disease, after heart disease
 The risk for suicide associated with depressive
disorders is elevated 12 to 20 fold compared to the
general population

6. Diagnosis Criteria DSM IV
 At least five of the following symptoms have been
present during the same 2- week period and
represent a change from previous functioning; at least
one of the symptoms is either
 1) depressed mood
 2) loss of interest or pleasure

7. Most of the day, nearly every day
For 2 Weeks
1. Depressed mood
2. Diminished interest or pleasure
3. weight loss
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation (Slow)
6. loss of energy
7. Worthlessness/guilt
8. Diminished ability to think or concentrate
9. Recurrent thoughts of death

8. Severity
 Mild
 few, if any, symptoms in excess of those required to
make the diagnosis and symptoms result in only
minor impairment in occupational functioning or in
usual social activities or relationships with others.

9. Severity
 Moderate
 symptoms or functional impairment between
“mild” and “severe”
 Severe without psychotic symptoms
 several symptoms in excess of those required to
make the diagnosis, and symptoms markedly interfere
with occupational functioning or with usual social
activities or relationships with others.

10. Severity
 Severe with psychotic symptoms
 delusions or hallucinations
 In partial remission
 symptoms of a major depressive episode are
present but full criteria are not met, or there is a period
without any significant symptoms of a major depressive
episode lasting less than 2 months following the end of
the major depressive episode

11. Severity
 In full remission : during the last 2 months, no
significant signs or symptoms of the
 disturbance were present.

12. Risk Of Suicide
 Loss of relationship
 Financial or occupational difficulties
 Poor social support
 Past suicide attempt
 Family history of suicide
 Alcohol abuse/dependence
 Other co-morbidities
 Suicidal ideation
 Severity of depression
 Psychomotor agitation
 Low self-esteem
 Hopelessness

13. History
 Presenting symptoms
 Mode of onset
 Duration and severity of symptoms
 Number and severity of past episodes
 Response to treatment
 Hospitalisations
 Psychosocial stressors
 Family history
 Suicide attempts
 Past history of manic or hypomanic episodes
 Substance abuse or other psychiatric illnesses
 Social history and social support

14. Presenting symptoms
 “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?"
 Common complaints
 Difficulty to sleep
 Multiple pain symptoms

15. Mode of onset
 Death of love one
 Financial problem
 Heartbroken

16. Duration and severity of symptoms
 Days/weeks
 Assess severity according to social/occupational
functioning

17. Number and severity of past
episodes
 Previous events
 History of taking antidepressants or sleeping pills e.g.
Lorazepam, Stillnox

18. Response to treatment
 Duration of taking antidepressants
 Any counselling session

19. Hospitalisations
 Duration of hospitalizaion
 Medications
 beta-blockers, methyldopa, clonidine, nifedipine,
digoxin, L-dopa, tetrabenazine

20. Psychosocial stressors
 Ongoing stressors
 Family crisis
 Debt
 Work stress

21. Family history
 Suicide
 Attempt suicide
 Other Mental Ilness e.g. Schizophenia, BMD
 Anxiety disorder

22. Suicide attempts
 Type of attempt
 Hang
 Cut Wrist
 Jump from high building

23. Past history of manic or hypomanic
episodes
 Excessively Happy
 Grandiosity
 Talkative
 Less need of sleep & not tired
 Increase goal directed activity

24. Substance abuse or other
psychiatric illnesses
 Amphetamine/Metamphetamine
 Pill Kuda, ICE, Syabu
 Glue Sniffing
 Gam cap Senapang
 Sleeping Pills

25. Social history and social support
 Good & Supporting Family, Good financial status will
bring a good outcome

26. Indications for referral to
Psychiatric Services
 Unsure of diagnosis
 Attempted suicide
 Active suicidal ideas / plans
 Failure to respond to treatment
 Advice on further treatment
 Clinical deterioration
 Recurrent episode within 1 year
 Psychotic symptoms
 Severe agitation
 Self neglect

27. Indications for admission
 Risk of harm to self
 Psychotic symptoms
 Inability to care for self
 Lack of impulse control
 Danger to others

28. Examination
 MSE
 Appearance e.g. well kempt, clothing, hair style,
appropriateness, calmness
 Facial expression
 Cooperativeness
 Speech e.g relevant/rational/coherent
 Mood e.g. Low Mood/euthymic/elated
 Affect e.g Restricted/depressed/broad
 Hallucination e.g Hearing Voices (Through ears, clearly
heard, nor before/after sleep)
 Delusion e.g People want to harm him, etc
 Insight e.g willingness to seek treatment

29. Investigation
 TRO Hypothyroidism, hypercalcaemia, Cushing’s
disease
 Thyroid Function
 Baseline Renal Function, LFT, Serum Cholestrol

30. Treatment
 Refer Psychiatry
 Psychoterapy
 Medication
 SSRI (1st Line)
 Fluvoxamine 50 mg ON x 3/7, then 100mg ON for 2/52
 Take Effect at least 2 weeks
 Common side effect - anxiety. Weight gain
 Short Course Benzodiazepine
 T.Lorazepam 1mg ON x 3-5 Days